Basic Information
| Provider Information | |||||||||
| NPI: | 1255337945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CROIX ORTHOPAEDICS, PA | ||||||||
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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: | 5803 NEAL AVE N | ||||||||
| Address2: | |||||||||
| City: | OAK PARK HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550822177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514398807 | ||||||||
| FaxNumber: | 6514390232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | SULLIVAN | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6514398807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MN | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 32658100 | 05 | WI | MEDICAID | 329210000 | 05 | MN | MEDICAID |