Basic Information
| Provider Information | |||||||||
| NPI: | 1669426631 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRAND ITASCA CLINIC AND HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183263401 | ||||||||
| FaxNumber: | 2189991461 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 GOLF COURSE RD | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557448648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2183263401 | ||||||||
| FaxNumber: | 2189991461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | CHRISTENSEN | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2189991702 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | MN | N | Hospital Units | Rehabilitation Unit | 275N00000X | N | Hospital Units | Medicare Defined Swing Bed Unit | 282N00000X | 330789 | MN | N | Hospitals | General Acute Care Hospital | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 038345700 | 05 | MN | MEDICAID |