=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841307865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ST. JOSEPH'S MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2006
-----------------------------------------------------
Last Update Date | 12/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 523 N 3RD ST
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-7437
-----------------------------------------------------
Fax | 218-828-7469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 523 N 3RD ST
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-7437
-----------------------------------------------------
Fax | 218-828-7469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. DAVID L PILOT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 218-828-7642
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 330736
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------