Basic Information
| Provider Information | |||||||||
| NPI: | 1396717633 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLOUD PATHOLOGISTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7848 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563027848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202555838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202555838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | RENNER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3207611011 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
ID Information
| ID | Type | State | Issuer | Description | 655013400 | 05 | MN | MEDICAID |