| |
3701 12th St N Suite 100 Saint Cloud MN 56303-2255 | |
(320) 253-7257 | |
(320) 257-5671 |
Full Name | |
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Speciality | Clinic/Center |
Location | 3701 12th St N, Saint Cloud, Minnesota |
Authorized Official Name and Position | Michael A Blair (SR VP & CFO) |
Authorized Official Contact | 3202555665 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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1200 6th Ave N Saint Cloud MN 56303-2735 Ph: (320) 252-5131 | 3701 12th St N Suite 100 Saint Cloud MN 56303-2255 Ph: (320) 253-7257 |
NPI Number | 1164978219 |
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Provider Enumeration Date | 08/29/2016 |
Last Update Date | 11/19/2020 |
Medicare PECOS PAC ID | 2466363395 |
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Medicare Enrollment ID | O20170811001936 |
Identifier | Type | State | Issuer |
---|---|---|---|
1164978219 | NPI | - | NPPES |
110890 | Other | MN | UCARE |
990228700 | Other | MN | MEDICAID |
35580 | Other | MN | HEALTH PARTNERS |
6D053CE | Other | MN | BLUE CROSS BLUE SHIELD |
98-04122 | Other | MN | MEDICA |
N002912 | Other | MN | CHAMPUS |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261Q00000X | Clinic/center | (Minnesota) | Primary |
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