Healthcare Provider Details

I. General information

NPI: 1174809792
Provider Name (Legal Business Name): ST JOSEPH'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2011
Last Update Date: 02/26/2024
Certification Date: 02/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13060 ISLE DRIVE
BAXTER MN
56425
US

IV. Provider business mailing address

13060 ISLE DRIVE
BAXTER MN
56425
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-2880
  • Fax:
Mailing address:
  • Phone: 218-828-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN BOREN
Title or Position: VP OF FINANCE
Credential:
Phone: 218-786-1009