Basic Information
| Provider Information | |||||||||
| NPI: | 1205970894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. CROIX ORTHOPAEDICS, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ORTHOTIC CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5803 NEAL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550822177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Practice Location | |||||||||
| Address1: | 1715 TOWER DR. W SUITE 100 | ||||||||
| Address2: | HEARTLAND CENTER | ||||||||
| City: | STILLWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550827609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512754180 | ||||||||
| FaxNumber: | 6512752744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 07/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LINDSTROM | ||||||||
| AuthorizedOfficialFirstName: | AMY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF ANCILLARY SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 6513512728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. CROIX ORTHOPAEDICS, P.A. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 41657800 | 05 | WI | MEDICAID | 44582 | 01 | MN | HEALTHPARTNERS | OTHER | 8G895BR | 01 | MN | BLUE CROSS MN BLUE PLUS | OTHER | 9635801017818 | 01 | MN | PREFERRED ONE | OTHER | 942298600 | 05 | MN | MEDICAID | 102957 | 01 | MN | UCARE | OTHER |