Provider Demographics
NPI:1669426631
Name:GRAND ITASCA CLINIC AND HOSPITAL
Entity type:Organization
Organization Name:GRAND ITASCA CLINIC AND HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-999-1702
Mailing Address - Street 1:1700 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3727
Mailing Address - Country:US
Mailing Address - Phone:612-672-6740
Mailing Address - Fax:612-884-3592
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-326-3401
Practice Address - Fax:218-999-1461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN273Y00000X
275N00000X, 332B00000X, 261Q00000X
MN330789282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No273Y00000XHospital UnitsRehabilitation Unit
No275N00000XHospital UnitsMedicare Defined Swing Bed Unit
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN038345700Medicaid
MN1301110001Medicare NSC
MNCD7691Medicare ID - Type Unspecified
MN038345700Medicaid
MN24T064Medicare Oscar/Certification
MNDA4360Medicare ID - Type Unspecified
MN240064AMedicare ID - Type Unspecified
MNC02323Medicare ID - Type Unspecified