MEDICARE: SHAKOPEE MDEWAKANTON SIOUX COMMUNITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	341600000X	Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	77M49SH	OTHER	MN	BCBS

General Provider Information

NPI Number	:	1700890134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAKOPEE MDEWAKANTON SIOUX COMMUNITY

Provider Business Mailing Address
First Line	:	3920 13TH AVE E
Second Line	:	SUITE 6
City	:	HIBBING
State	:	MN
Zip	:	55746-3675
Country	:	US
Telephone Number	:	218-263-7540
Fax Number	:	866-732-0699

Provider Business Practice Location Address
First Line	:	2525 FLANDREAU TRAIL
Second Line	:
City	:	PRIOR LAKE
State	:	MN
Zip	:	55372
Country	:	US
Telephone Number	:	952-233-1077
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	STANLEY CROOKS
Credential	:
Telephone Number	:	952-445-8900

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	01/20/2025

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Directions to “SHAKOPEE MDEWAKANTON SIOUX COMMUNITY ” Practice Location

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