Basic Information
Provider Information | |||||||||
NPI: | 1568447027 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RIVER'S EDGE HOSPITAL & CLINIC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1900 SUNRISE DR | ||||||||
Address2: |   | ||||||||
City: | ST PETER | ||||||||
State: | MN | ||||||||
PostalCode: | 560825376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5079312200 | ||||||||
FaxNumber: | 5079348505 | ||||||||
Practice Location | |||||||||
Address1: | 1900 SUNRISE DR | ||||||||
Address2: |   | ||||||||
City: | ST PETER | ||||||||
State: | MN | ||||||||
PostalCode: | 560825376 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5079312200 | ||||||||
FaxNumber: | 5079347651 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2005 | ||||||||
LastUpdateDate: | 02/11/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SPIKE | ||||||||
AuthorizedOfficialFirstName: | COLLEEN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5079312200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 327494 | MN | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
No ID Information.