Provider Demographics
NPI:1285726067
Name:COOPERSTOWN MEDICAL CENTER
Entity type:Organization
Organization Name:COOPERSTOWN MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:STOMP
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LNHA
Authorized Official - Phone:701-797-2221
Mailing Address - Street 1:1200 ROBERTS AVE NE
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-7101
Mailing Address - Country:US
Mailing Address - Phone:701-797-2221
Mailing Address - Fax:
Practice Address - Street 1:1200 ROBERTS AVE NE
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-7101
Practice Address - Country:US
Practice Address - Phone:701-797-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOPERSTOWN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-29
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1012A314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND30095Medicaid
ND1107OtherBLUE CROSS BLUE SHIELD ND
ND4981850001Medicare NSC
ND71115Medicare UPIN
ND1107OtherBLUE CROSS BLUE SHIELD ND