Provider Demographics
NPI:1962548214
Name:COOPERSTOWN MEDICAL CENTER
Entity type:Organization
Organization Name:COOPERSTOWN MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN ASSIST/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-786-1709
Mailing Address - Street 1:107 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:COOPERSTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58425-4501
Mailing Address - Country:US
Mailing Address - Phone:701-786-1709
Mailing Address - Fax:701-786-7121
Practice Address - Street 1:107 12TH ST S
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:ND
Practice Address - Zip Code:58425-4501
Practice Address - Country:US
Practice Address - Phone:701-786-1709
Practice Address - Fax:701-786-7121
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COOPERSTOWN MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND4770OtherBLUE CROSS BLUE SHIELD
ND5000Medicaid
NDN71115Medicare PIN
ND4981850001Medicare NSC
ND4770OtherBLUE CROSS BLUE SHIELD