MEDICARE: ST. MARY'S REGIONAL HEALTH CENTER

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	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548604309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S REGIONAL HEALTH CENTER

Provider Business Mailing Address
First Line	:	1027 WASHINGTON AVE
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-3409
Country	:	US
Telephone Number	:	218-238-5901
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 1ST ST
Second Line	:
City	:	LAKE PARK
State	:	MN
Zip	:	56554-4311
Country	:	US
Telephone Number	:	218-238-5901
Fax Number	:

Authorized Official
Title or Position	:	COO
Name	:	ALAN HURLEY
Credential	:
Telephone Number	:	701-364-7667

Provider Enumeration Date	:	04/24/2013
Last Update Date	:	03/01/2024

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