NPIMap

Organization Active NPI

St. Mary's Regional Health Center

Doing business as Essentia Health St. Mary's - Lake Park Clinic

  • Family Medicine Physician
  • Lake Park, MN
National Provider Identifier
1548604309
Registry record updated Mar 1, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
ST. MARY'S REGIONAL HEALTH CENTER
Doing business as
Essentia Health St. Mary's - Lake Park Clinic
Practice address
1005 1St St
Lake Park, MN 56554-4311
Phone
(218) 238-5901
NPI assigned
Apr 24, 2013
Last updated
Mar 1, 2024By the provider in NPPES
Organization subpart
Yes
Parent organization
ESSENTIA HEALTHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 1, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Alan Hurley
Title
Coo
Phone
(701) 364-7667

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X NU Primary

Addresses

Primary practice location

1005 1St St
Lake Park, MN 56554-4311

Mailing address

1027 Washington Ave
Detroit Lakes, MN 56501-3409
Phone (218) 238-5901

Other identifiers 1

IdentifierTypeStateIssuer
892442000MedicaidMN

Other names 1

  • Essentia Health St. Mary's - Lake Park Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20031117000090 MN Part B Supplier - Clinic/Group Practice 2062326820 Receives reassigned benefits from 290 practitioners
13 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Frazee, MN; Lake Park, MN; Mahnomen, MN; Menahga, MN; Park Rapids, MN; Pelican Rapids, MN; Walker, MN; Detroit Lakes, MN

Other NPIs on the same Medicare enrollment 13

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 13

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2309672Essentia Health St. Mary's-Lake Park Clinic1005 1St St, Lake Park, MN 56554Certificate of waiverAug 19, 2026

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

  • Innovis Health LLC

    dba Essentia Health-North Fargo Clinic

    • Occupational Medicine Clinic/Center
    • Fargo, ND
    • NPI 1568918902

    Member Of

    NPD member

Locations

1103 1st St E
Park Rapids, MN 56470
Phone (218) 732-0542

705 Pleasant Ave S
Park Rapids, MN 56470
Phone (218) 732-2800

Practitioners & affiliated clinicians

Practitioners 33

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 33

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1366761600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1709251200000",
    "number": "1548604309",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1027 WASHINGTON AVE",
            "city": "DETROIT LAKES",
            "state": "MN",
            "postal_code": "565013409",
            "telephone_number": "218-238-5901"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1005 1ST ST",
            "city": "LAKE PARK",
            "state": "MN",
            "postal_code": "565544311",
            "telephone_number": "218-238-5901"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ST. MARY'S REGIONAL HEALTH CENTER",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "ESSENTIA HEALTH",
        "enumeration_date": "2013-04-24",
        "last_updated": "2024-03-01",
        "certification_date": "2024-03-01",
        "status": "A",
        "authorized_official_last_name": "HURLEY",
        "authorized_official_first_name": "ALAN",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "701-364-7667"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "892442000",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Essentia Health St. Mary's - Lake Park Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Essentia Health St. Mary's - Lake Park Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Park, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 1, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.