Basic Information
| Provider Information | |||||||||
| NPI: | 1447231188 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ANESTHESIA ASSOCIATES OF ST. CLOUD, LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 12TH ST N | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 08/08/2011 | ||||||||
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| AuthorizedOfficialLastName: | ZOELLER | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3202583090 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 313 | MN | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 977208100 | 05 | MN | MEDICAID |