Healthcare Provider Details

I. General information

NPI: 1194769265
Provider Name (Legal Business Name): NORTHERN ITASCA HOSPITAL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

258 PINE TREE DRIVE
BIGFORK MN
56628
US

IV. Provider business mailing address

258 PINE TREE DRIVE P.O. BOX 258
BIGFORK MN
56628
US

V. Phone/Fax

Practice location:
  • Phone: 218-743-3177
  • Fax: 218-743-3559
Mailing address:
  • Phone: 218-743-3177
  • Fax: 218-743-3559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number331040
License Number StateMN

VIII. Authorized Official

Name: MR. HAROLD DANIEL ODEGAARD
Title or Position: CEO
Credential:
Phone: 218-743-3177