Basic Information
| Provider Information | |||||||||
| NPI: | 1225030844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRACARE CLINIC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRACARE - PLAZA CLINIC (WOMEN & CHILDREN) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202294977 | ||||||||
| FaxNumber: | 3206543667 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIRCLE | ||||||||
| Address2: | CENTRACARE CLINIC-WOMEN & CHILDREN | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP & CFO | ||||||||
| AuthorizedOfficialTelephone: | 3202555665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRACARE CLINIC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 261QM1300X | MN | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 052720300 | 05 | MN | MEDICAID | NA139 | 01 | PREF ONE | OTHER | 35580 | 01 | HEALTH PARTNERS | OTHER | 110382 | 01 | UCARE | OTHER | 98-12146 | 01 | MEDICA | OTHER | 50A45CE | 01 | BCBS | OTHER | 50A61CE | 01 | BCBS | OTHER |