Provider Demographics
NPI:1033391099
Name:ST. CLOUD HOSPITAL
Entity Type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:CENTRACARE KIDNEY PROGRAM - LITCHFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1900
Mailing Address - Country:US
Mailing Address - Phone:320-240-7808
Mailing Address - Fax:320-240-7840
Practice Address - Street 1:520 HWY 12 EAST
Practice Address - Street 2:SUITE 6
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355
Practice Address - Country:US
Practice Address - Phone:320-240-7808
Practice Address - Fax:320-240-7840
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLOUD HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-03
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN243536Medicare Oscar/Certification