Basic Information
| Provider Information | |||||||||
| NPI: | 1891778155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNERATH | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 CENTRACARE CIR | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563035000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3206543630 | ||||||||
| FaxNumber: | 3206543657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 36914 | MN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1001398 | 01 | PREFERRED ONE | OTHER | 110412 | 01 | U CARE | OTHER | COMP | 01 | CHAMPUS | OTHER | 2114043 | 01 | FIRST HEALTH PLAN | OTHER | 572105 | 01 | ARAZ GROUP AMERICAS PPO | OTHER | 1202203 | 01 | MEDICA HEALTH PLANS | OTHER | 51A37MI | 01 | BLUE CROSS BLUE SHIELD | OTHER | COMP | 01 | ONE HEALTH PLAN GREAT WES | OTHER | HP27103 | 01 | HEALTH PARTNERS | OTHER | COMP | 01 | MMSI | OTHER | 620027300 | 01 | MN | MEDIAL ASSISTANCE | OTHER |