Basic Information
| Provider Information | |||||||||
| NPI: | 1598713075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRACARE HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTRACARE LABORATORY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVE N | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202555711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | CENTRACARE HEALTH PLAZA | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3202555711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | KLUGHERZ | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3202555665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRACARE HEALTH SYSTEMS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 24D0405790 | MN | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 690009424 | 01 | MN | RR MEDICARE | OTHER | 443985600 | 05 | MN | MEDICAID |