Basic Information
| Provider Information | |||||||||
| NPI: | 1780675843 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MELLOY | ||||||||
| FirstName: | CINDA | ||||||||
| MiddleName: | JENSEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | CENTRACARE CLINIC | ||||||||
| City: | ST CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 32044 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 110409 | 01 | U CARE | OTHER | 51A33JE | 01 | BLUE CROSS BLUE SHIELD | OTHER | HP25485 | 01 | HEALTH PARTNERS | OTHER | 254011 | 01 | PREFERRED ONE | OTHER | 763855 | 01 | ARAZ GROUP | OTHER | 1202202 | 01 | MEDICA HEALTH PLANS | OTHER | 659588000 | 01 | MEDICAL ASSISTANCE | OTHER | 2114179 | 01 | FIRST HEALTH PLAN | OTHER |