Basic Information
| Provider Information | |||||||||
| NPI: | 1235157462 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGINA MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | REGINA MEDICAL CENTER PSYCH UNIT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1175 NININGER RD | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550331056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514804100 | ||||||||
| FaxNumber: | 6514804212 | ||||||||
| Practice Location | |||||||||
| Address1: | 1175 NININGER RD | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550331056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514804100 | ||||||||
| FaxNumber: | 6514804212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/09/2013 | ||||||||
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| AuthorizedOfficialLastName: | ERICKSON | ||||||||
| AuthorizedOfficialFirstName: | TY | ||||||||
| AuthorizedOfficialMiddleName: | W. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6514041450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGINA MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 566245100 | 05 | MN | MEDICAID | CD5135 | 01 | MN | RR MEDICARE | OTHER |