Provider Demographics
NPI:1720086028
Name:CCM HEALTH
Entity type:Organization
Organization Name:CCM HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DESERAE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANSPACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-269-8877
Mailing Address - Street 1:824 N 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MONTEVIDEO
Mailing Address - State:MN
Mailing Address - Zip Code:56265-1629
Mailing Address - Country:US
Mailing Address - Phone:320-269-8877
Mailing Address - Fax:320-269-8186
Practice Address - Street 1:824 N 11TH ST
Practice Address - Street 2:
Practice Address - City:MONTEVIDEO
Practice Address - State:MN
Practice Address - Zip Code:56265
Practice Address - Country:US
Practice Address - Phone:320-269-8877
Practice Address - Fax:320-269-8186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-11
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261Q00000X
MN327693282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN855345900Medicaid
MN855345900Medicaid
MN0776390001Medicare ID - Type UnspecifiedB-D-MERC
MN241325Medicare ID - Type UnspecifiedA-CAH
MN24Z325Medicare Oscar/Certification
MN247216Medicare ID - Type UnspecifiedHOME HEALTH
MNC01552Medicare ID - Type UnspecifiedB-ER-PHY-RR
MNC03771Medicare ID - Type UnspecifiedB-CLINIC