Provider Demographics
NPI:1467499293
Name:ST CLOUD MN OPHTHALMOLOGY ASC LLC
Entity Type:Organization
Organization Name:ST CLOUD MN OPHTHALMOLOGY ASC LLC
Other - Org Name:ST. CLOUD CENTER FOR OPHTHALMIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SNODGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-665-1283
Mailing Address - Street 1:1A BURTON HILLS BLVD # L&C
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-6187
Mailing Address - Country:US
Mailing Address - Phone:615-665-1283
Mailing Address - Fax:615-234-1720
Practice Address - Street 1:2055 15TH ST N
Practice Address - Street 2:SUITE B
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1747
Practice Address - Country:US
Practice Address - Phone:320-258-6620
Practice Address - Fax:320-258-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331176261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN837620400Medicaid
MN837620400Medicaid
MN490000053Medicare PIN
MN837620400Medicaid
MNPOO309772Medicare PIN