Basic Information
Provider Information | |||||||||
NPI: | 1922337344 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL MINNESOTA GROUP HEALTH, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HEALTHPARTNERS SLEEP HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1245 15TH ST N | ||||||||
Address2: |   | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563031802 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202535220 | ||||||||
FaxNumber: | 3202032075 | ||||||||
Practice Location | |||||||||
Address1: | 622 ROOSEVELT RD | ||||||||
Address2: | DISTRICT SQUARE SUITE 140 | ||||||||
City: | SAINT CLOUD | ||||||||
State: | MN | ||||||||
PostalCode: | 563014867 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202032380 | ||||||||
FaxNumber: | 3202032381 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/14/2009 | ||||||||
LastUpdateDate: | 12/14/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VINSON | ||||||||
AuthorizedOfficialFirstName: | ANDREW | ||||||||
AuthorizedOfficialMiddleName: | J. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 3202032020 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X |   | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |   |
No ID Information.