MEDICARE: INDEPENDENT SCHOOL DISTRICT #881

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251300000X	Local Education Agency (LEA)		MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	736128900	OTHER	MN	MEDICAL ASSISTANCE

General Provider Information

NPI Number	:	1316015290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT SCHOOL DISTRICT #881

Provider Business Mailing Address
First Line	:	200 STATE HIGHWAY 55 EAST
Second Line	:	BOX 820
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-0820
Country	:	US
Telephone Number	:	320-963-3171
Fax Number	:	320-963-3170

Provider Business Practice Location Address
First Line	:	200 STATE HIGHWAY 55 EAST
Second Line	:	BOX 820
City	:	MAPLE LAKE
State	:	MN
Zip	:	55358-0820
Country	:	US
Telephone Number	:	320-963-3171
Fax Number	:	320-963-3170

Authorized Official
Title or Position	:	SUPERINTENDENT
Name	:	MARK REDEMSKE
Credential	:
Telephone Number	:	320-963-3114

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	06/17/2008

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