Healthcare Provider Details

I. General information

NPI: 1730134891
Provider Name (Legal Business Name): ST. JOSEPH'S MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 02/27/2024
Certification Date: 02/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4317 W WOODMAN ST
PEQUOT LAKES MN
56472-3473
US

IV. Provider business mailing address

4317 W WOODMAN ST
PEQUOT LAKES MN
56472-3473
US

V. Phone/Fax

Practice location:
  • Phone: 218-568-4416
  • Fax: 218-568-4625
Mailing address:
  • Phone: 218-568-4416
  • Fax: 218-568-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number330736
License Number StateMN

VIII. Authorized Official

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