Provider Demographics
NPI:1700955366
Name:GEROPSYCH HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:GEROPSYCH HEALTH SERVICES, INC.
Other - Org Name:GEROPSYCH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SAUNDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ST. MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-CNS
Authorized Official - Phone:218-209-1137
Mailing Address - Street 1:611 SPRUCE GROVE LN NW
Mailing Address - Street 2:P.O. BOX 155
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-7746
Mailing Address - Country:US
Mailing Address - Phone:218-209-1137
Mailing Address - Fax:218-333-0335
Practice Address - Street 1:611 SPRUCE GROVE LN NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-7746
Practice Address - Country:US
Practice Address - Phone:218-209-1137
Practice Address - Fax:218-333-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1077485364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNDC6885OtherRR MEDICARE
MN0199999OtherMEDICA
ND13481Medicaid
MN014080500Medicaid
ND13481OtherND DEFINITY
MNC03742Medicare ID - Type UnspecifiedMEDICARE