Provider Demographics
NPI:1053342329
Name:BRAINERD MEDICAL CENTER INC
Entity type:Organization
Organization Name:BRAINERD MEDICAL CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-1009
Mailing Address - Street 1:204 BELKNAP ST
Mailing Address - Street 2:ATN: PHARMACY SERVICES
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-2905
Mailing Address - Country:US
Mailing Address - Phone:218-786-4265
Mailing Address - Fax:218-786-2198
Practice Address - Street 1:2024 S 6TH ST
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-4529
Practice Address - Country:US
Practice Address - Phone:218-829-7455
Practice Address - Fax:218-855-5205
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ESSENTIA HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2024-02-23
Deactivation Date:2021-09-03
Deactivation Code:
Reactivation Date:2021-09-14
Provider Licenses
StateLicense IDTaxonomies
MN3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5866850001Medicare NSC
MN0713230001Medicare NSC