Provider Demographics
NPI:1144507708
Name:ST. MARY'S MEDICAL CENTER
Entity type:Organization
Organization Name:ST. MARY'S MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EVP HOSPITAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:GARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-786-4878
Mailing Address - Street 1:1001 KENWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2370
Mailing Address - Country:US
Mailing Address - Phone:218-723-6564
Mailing Address - Fax:218-723-6548
Practice Address - Street 1:1001 KENWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-2370
Practice Address - Country:US
Practice Address - Phone:218-723-6564
Practice Address - Fax:218-723-6548
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S DULUTH CLINIC HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-10
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN355203251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0049-0050996OtherMEDICA - ELDERLY WAIVER