Provider Demographics
NPI:1164978219
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:MIDSOTA PLASTIC & RECONSTRUCTIVE SURGEONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:
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 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:3701 12TH ST N
Practice Address - Street 2:SUITE 100
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2255
Practice Address - Country:US
Practice Address - Phone:320-253-7257
Practice Address - Fax:320-257-5671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-29
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110890OtherUCARE
MN990228700OtherMEDICAID
MN35580OtherHEALTH PARTNERS
MN6D053CEOtherBLUE CROSS BLUE SHIELD
MN98-04122OtherMEDICA
MNN002912OtherCHAMPUS
MN110890OtherUCARE
MNN002912OtherCHAMPUS