Provider Demographics
NPI:1508882754
Name:ST. CLOUD EAR, NOSE & THROAT CLINIC, P.A.
Entity Type:Organization
Organization Name:ST. CLOUD EAR, NOSE & THROAT CLINIC, P.A.
Other - Org Name:ST. CLOUD EAR, NOSE & THROAT - HEAD & NECK CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:RESSEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-257-1167
Mailing Address - Street 1:1528 NORTHWAY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1255
Mailing Address - Country:US
Mailing Address - Phone:320-252-0233
Mailing Address - Fax:
Practice Address - Street 1:1528 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1255
Practice Address - Country:US
Practice Address - Phone:320-252-0233
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN55319CLOtherBLUE CROSS BLUE SHIELD
MN508208100Medicaid
MN508208100Medicaid