MEDICARE: PHS INDIAN HOSPITAL

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	1223G0001X	General Practice Dentistry		MN

General Provider Information

NPI Number	:	1609392992
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHS INDIAN HOSPITAL

Provider Business Mailing Address
First Line	:	24760 HOSPITAL DRIVE
Second Line	:	BOX 497 C/O BUSINESS OFFICE
City	:	RED LAKE
State	:	MN
Zip	:	56671
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0181

Provider Business Practice Location Address
First Line	:	PO BOX 497
Second Line	:
City	:	REDLAKE
State	:	MN
Zip	:	56671-0497
Country	:	US
Telephone Number	:	218-679-3912
Fax Number	:	218-679-0181

Authorized Official
Title or Position	:	BUSINESS OFFICE MANAGER
Name	:	JANICE MARIE THUNDER
Credential	:
Telephone Number	:	218-679-3912

Provider Enumeration Date	:	08/17/2017
Last Update Date	:	07/21/2022

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1679099568 — PHS INDIAN HOSPITAL
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PO BOX 497
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Directions to “PHS INDIAN HOSPITAL ” Practice Location

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