Provider Demographics
NPI:1982919395
Name:INTEGRACARE LTD
Entity type:Organization
Organization Name:INTEGRACARE LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RANDY
Authorized Official - Last Name:HALSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-251-2600
Mailing Address - Street 1:100 SOUTH 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377
Mailing Address - Country:US
Mailing Address - Phone:320-251-2600
Mailing Address - Fax:320-251-4763
Practice Address - Street 1:100 SOUTH 2ND STREET
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377
Practice Address - Country:US
Practice Address - Phone:320-251-2600
Practice Address - Fax:320-251-4763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-10
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1491207Q00000X, 225100000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN079858400Medicaid
MN1219767OtherARAZ
MN31T18INOtherCCS
MN1770646937OtherHUMANA
MN169318P539OtherUCARE
MN1770646937OtherTRICARE
MN1770646937OtherAETNA
MN1770646937OtherUNITED HEALTH CARE
MN31T18INOtherBCBS
MNCH3371OtherRAILROAD MEDICARE
MN1770646937OtherPREFERRED ONE
MN1770646937OtherSELECT CARE
MN1770646937OtherMMSI
MN9823046OtherMEDICA
MN1770646937OtherUNICARE
MN1770646937OtherUNICARE