Healthcare Provider Details

I. General information

NPI: 1962548214
Provider Name (Legal Business Name): COOPERSTOWN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 12TH ST S
COOPERSTOWN ND
58425-4501
US

IV. Provider business mailing address

107 12TH ST S
COOPERSTOWN ND
58425-4501
US

V. Phone/Fax

Practice location:
  • Phone: 701-786-1709
  • Fax: 701-786-7121
Mailing address:
  • Phone: 701-786-1709
  • Fax: 701-786-7121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KELLEY SHAWN
Title or Position: ADMIN ASSIST/CREDENTIALING
Credential:
Phone: 701-786-1709