Provider Demographics
NPI:1598713075
Name:CENTRACARE HEALTH SYSTEM
Entity Type:Organization
Organization Name:CENTRACARE HEALTH SYSTEM
Other - Org Name:CENTRACARE LABORATORY SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:KLUGHERZ
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:320-251-2700
Mailing Address - Fax:320-255-5711
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:CENTRACARE HEALTH PLAZA
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-255-5711
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE HEALTH SYSTEMS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-05
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24D0405790291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN690009424OtherRR MEDICARE
MN443985600Medicaid
MN690009424OtherRR MEDICARE