Provider Demographics
NPI:1881954147
Name:NORTHERN PINES MEDICAL CENTER
Entity type:Organization
Organization Name:NORTHERN PINES MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ACKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-229-4222
Mailing Address - Street 1:5211 HIGHWAY 110
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MN
Mailing Address - Zip Code:55705-1522
Mailing Address - Country:US
Mailing Address - Phone:218-229-2211
Mailing Address - Fax:
Practice Address - Street 1:5211 HIGHWAY 110
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:MN
Practice Address - Zip Code:55705-1522
Practice Address - Country:US
Practice Address - Phone:218-229-2211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-21
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00604261QC0050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1881954147Medicaid
MN1881954147Medicaid
MN241340Medicare Oscar/Certification