Provider Demographics
NPI:1770542904
Name:ELY-BLOOMENSON COMMUNITY HOSPITAL
Entity type:Organization
Organization Name:ELY-BLOOMENSON COMMUNITY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSSUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-365-3271
Mailing Address - Street 1:328 W CONAN ST
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1145
Mailing Address - Country:US
Mailing Address - Phone:218-365-3271
Mailing Address - Fax:218-365-8777
Practice Address - Street 1:328 W CONAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1145
Practice Address - Country:US
Practice Address - Phone:218-365-3271
Practice Address - Fax:218-365-8777
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN327664282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN122747500Medicaid
MN0507540001Medicare NSC
MNC06031Medicare ID - Type UnspecifiedPART B MEDICARE
MN122747500Medicaid
MN245138Medicare Oscar/Certification
MN247172Medicare ID - Type UnspecifiedHOME HEALTH
MN241318Medicare Oscar/Certification