Basic Information
| Provider Information | |||||||||
| NPI: | 1487690996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST CLOUD MEDICAL GROUP PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 COUNTY ROAD 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563034872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202028949 | ||||||||
| FaxNumber: | 3202020756 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 COUNTY ROAD 120 | ||||||||
| Address2: | |||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563034872 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202028949 | ||||||||
| FaxNumber: | 3202020756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 10/06/2011 | ||||||||
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| AuthorizedOfficialLastName: | TACL | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3202028949 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 175710500 | 05 | MN | MEDICAID |