Healthcare Provider Details

I. General information

NPI: 1851546162
Provider Name (Legal Business Name): GLENCOE REGIONAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 HENNEPIN AVE. NO.
GLENCOE MN
55336-1416
US

IV. Provider business mailing address

1805 HENNEPIN AVE. NO.
GLENCOE MN
55336-1416
US

V. Phone/Fax

Practice location:
  • Phone: 320-864-3121
  • Fax: 320-864-7880
Mailing address:
  • Phone: 320-864-3121
  • Fax: 320-864-7880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MR. JON D. BRABAND
Title or Position: PRESIDENT & CEO
Credential:
Phone: 320-864-7752