Provider Demographics
NPI:1467615294
Name:ST. CLOUD HOSPITAL
Entity Type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:RECOVERY PLUS ADULT PROGRAM-ST CLOUD HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT & 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:320-229-3761
Mailing Address - Fax:320-656-7009
Practice Address - Street 1:713 ANDERSON AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2048
Practice Address - Country:US
Practice Address - Phone:320-229-3761
Practice Address - Fax:320-656-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-02
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN803875 3 CDT276400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes276400000XHospital UnitsRehabilitation, Substance Use Disorder Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN240036Medicare Oscar/Certification