Basic Information
| Provider Information | |||||||||
| NPI: | 1619934627 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. CLOUD HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1406 6TH AVE NORTH | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1406 6TH AVE NORTH | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563031900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202512700 | ||||||||
| FaxNumber: | 3206567009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 10/10/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLAIR | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT AND CFO | ||||||||
| AuthorizedOfficialTelephone: | 3202555665 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 331506 | MN | N | Hospital Units | Psychiatric Unit | 273Y00000X | 331506 | MN | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 883747300 | 05 | MN | MEDICAID | 883747301 | 05 | MN | MEDICAID |