Provider Demographics
NPI:1063549822
Name:PHS INDIAN HOSPITAL
Entity type:Organization
Organization Name:PHS INDIAN HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THUNDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-679-0148
Mailing Address - Street 1:4100 W. 150TH ST
Mailing Address - Street 2:LB: 95419
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24670 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:RED LAKE
Practice Address - State:MN
Practice Address - Zip Code:56671
Practice Address - Country:US
Practice Address - Phone:218-679-0173
Practice Address - Fax:218-679-0189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0002X, 3336S0011X
MN2604653332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2046533OtherPK
MN476753500Medicaid