Provider Demographics
NPI:1184664674
Name:STELLIS HEALTH, PA
Entity Type:Organization
Organization Name:STELLIS HEALTH, PA
Other - Org Name:BUFFALO CLINIC, MONTICELLO CLINIC, ALBERTVILLE/ST.MICHAEL CLINIC,
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:S
Authorized Official - Last Name:HALVORSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-295-2921
Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-682-1313
Mailing Address - Fax:763-684-3790
Practice Address - Street 1:1700 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1930
Practice Address - Country:US
Practice Address - Phone:763-682-1313
Practice Address - Fax:763-684-3790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN520261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN222310400Medicaid
MN0514560002Medicare NSC
MN222310400Medicaid