Basic Information
Provider Information | |||||||||
NPI: | 1548256753 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LUTHERAN CHARITY ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | JAMESTOWN REGIONAL MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: | 7019523265 | ||||||||
Practice Location | |||||||||
Address1: | 2422 20TH ST SW | ||||||||
Address2: |   | ||||||||
City: | JAMESTOWN | ||||||||
State: | ND | ||||||||
PostalCode: | 584016201 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7012521050 | ||||||||
FaxNumber: | 7019523265 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 04/01/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DELFS | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7019524850 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 5027A | ND | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 1452345 | 05 | ND |   | MEDICAID |