Basic Information
| Provider Information | |||||||||
| NPI: | 1851388920 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDCENTRA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 SMITH AVE N | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512885180 | ||||||||
| FaxNumber: | 6512885188 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 SMITH AVE N | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551022534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512885180 | ||||||||
| FaxNumber: | 6512885188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SISKA | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/ | ||||||||
| AuthorizedOfficialTelephone: | 7635453006 | ||||||||
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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 | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.