Basic Information
Provider Information | |||||||||
NPI: | 1033451620 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. CROIX REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LINDSTROM CLINIC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 235 E STATE ST | ||||||||
Address2: |   | ||||||||
City: | SAINT CROIX FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 540244117 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7154833221 | ||||||||
FaxNumber: | 7154830507 | ||||||||
Practice Location | |||||||||
Address1: | 12375 LINDSTROM LN | ||||||||
Address2: |   | ||||||||
City: | LINDSTROM | ||||||||
State: | MN | ||||||||
PostalCode: | 550459551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514002240 | ||||||||
FaxNumber: | 7154830507 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2013 | ||||||||
LastUpdateDate: | 09/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUSO | ||||||||
AuthorizedOfficialFirstName: | MIKE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 7154830556 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QR1300X | 1041 | WI | N |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health | 3336C0002X |   |   | N |   | Suppliers | Pharmacy | Clinic Pharmacy | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.