Provider Demographics
NPI:1700162328
Name:BRAINERD MEDICAL CENTER INC
Entity Type:Organization
Organization Name:BRAINERD MEDICAL CENTER INC
Other - Org Name:ESSENTIA HEALTH - BAXTER SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-828-7656
Mailing Address - Street 1:13060 ISLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BAXTER
Mailing Address - State:MN
Mailing Address - Zip Code:56425
Mailing Address - Country:US
Mailing Address - Phone:218-828-2880
Mailing Address - Fax:
Practice Address - Street 1:13060 ISLE DRIVE
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-828-2880
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAINERD MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-10-27
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC04423Medicare PIN