Provider Demographics
NPI:1407858020
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE - PLAZA CLINIC
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:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-229-4977
Mailing Address - Fax:
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:CENTRACARE CLINIC HEALTH PLAZA
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-252-2422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-12
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN411086657261QM1300X
261QM1300X, 261QU0200X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
498R1CEOtherBCBS
170317OtherUCARE
35580OtherHEALTH PARTNERS
MN052720300Medicaid
NA356OtherPREF ONE
MN052720303Medicaid
98-00211OtherMEDICA
MN052720300Medicaid
498R1CEOtherBCBS
MNC03065Medicare PIN