Healthcare Provider Details

I. General information

NPI: 1912121484
Provider Name (Legal Business Name): ELY BLOOMENSON COMMUNITY HOSPITAL & NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2007
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 W CONAN STREET
ELY MN
55731-1198
US

IV. Provider business mailing address

328 W CONAN STREET
ELY MN
55731-1198
US

V. Phone/Fax

Practice location:
  • Phone: 218-365-3271
  • Fax: 218-365-8777
Mailing address:
  • Phone: 218-365-3271
  • Fax: 218-365-8777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number2004567
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number327664
License Number StateMN

VIII. Authorized Official

Name: CONNIE J KATZIAN
Title or Position: BUSINESS OFFICE MANAGER
Credential:
Phone: 218-365-8761