Healthcare Provider Details

I. General information

NPI: 1639648348
Provider Name (Legal Business Name): ST JOSEPH'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2018
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 S 6TH ST
BRAINERD MN
56401-4528
US

IV. Provider business mailing address

2019 S 6TH ST
BRAINERD MN
56401-4528
US

V. Phone/Fax

Practice location:
  • Phone: 218-822-6736
  • Fax: 218-822-3758
Mailing address:
  • Phone: 218-822-6736
  • Fax: 218-822-3758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

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