Provider Demographics
NPI:1104988229
Name:ST. MARY'S REGIONAL HEALTH CENTER
Entity type:Organization
Organization Name:ST. MARY'S REGIONAL HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINKMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:218-847-0700
Mailing Address - Street 1:1040 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3508
Mailing Address - Country:US
Mailing Address - Phone:218-847-0820
Mailing Address - Fax:218-844-0780
Practice Address - Street 1:1040 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3508
Practice Address - Country:US
Practice Address - Phone:218-847-0820
Practice Address - Fax:218-844-0780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN332297332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1A755MAOtherBLUE CROSS BLUE SHIELD MN
MN30393OtherNORTH DAKOTA MEDICAID
MN1041862OtherPREFERRED ONE
MN623840800Medicaid
MN7122625OtherMEDICA
MN30393OtherNORTH DAKOTA MEDICAID