Basic Information
| Provider Information | |||||||||
| NPI: | 1548212699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MILLE LACS HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRITICAL ACCESS HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | PO BOX A | ||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 ELM ST N | ||||||||
| Address2: | |||||||||
| City: | ONAMIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563597901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205323154 | ||||||||
| FaxNumber: | 3205323111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/26/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | UNZEN | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3205322581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MILLE LACS HEALTH SYSTEM | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 3336I0012X | 201047-0 | MN | N | Suppliers | Pharmacy | Institutional Pharmacy | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 251E00000X | 343531 | MN | N | Agencies | Home Health | 282NC0060X | 331503 | MN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 52204CO | 01 | MN | BLUE CROSS HOSPITAL | OTHER | 5012782 | 01 | MN | MEDICA | OTHER | 33523MI | 01 | MN | BLUE CROSS CLINICS | OTHER | 1006091 | 01 | MN | PREFERRED ONE | OTHER | 190247400 | 05 | MN | MEDICAID |