Basic Information
| Provider Information | |||||||||
| NPI: | 1265404115 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILLMAR MEDICAL SERVICES, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1320 1ST ST S | ||||||||
| Address2: | PO BOX 773 | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202356506 | ||||||||
| FaxNumber: | 3202357069 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 1ST ST S | ||||||||
| Address2: | |||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014242 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202356506 | ||||||||
| FaxNumber: | 3202357069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2006 | ||||||||
| LastUpdateDate: | 08/27/2012 | ||||||||
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| AuthorizedOfficialLastName: | TONE | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3202316766 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 327471 | MN | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8816WI | 01 | MN | BLUE CROSS OF MN | OTHER | 369312100 | 05 | MN | MEDICAID |