Basic Information
Provider Information | |||||||||
NPI: | 1467615294 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. CLOUD HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RECOVERY PLUS ADULT PROGRAM-ST CLOUD HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1406 6TH AVE N | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563031900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202293761 | ||||||||
FaxNumber: | 3206567009 | ||||||||
Practice Location | |||||||||
Address1: | 713 ANDERSON AVE | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563032048 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202293761 | ||||||||
FaxNumber: | 3206567009 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2008 | ||||||||
LastUpdateDate: | 10/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLAIR | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT & CFO | ||||||||
AuthorizedOfficialTelephone: | 3202555665 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 276400000X | 803875 3 CDT | MN | Y |   | Hospital Units | Rehabilitation, Substance Use Disorder Unit |   |
No ID Information.