Provider Demographics
NPI:1629070230
Name:CENTRACARE CLINIC MELROSE
Entity Type:Organization
Organization Name:CENTRACARE CLINIC MELROSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:FELDHEGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-240-2152
Mailing Address - Street 1:525 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MN
Mailing Address - Zip Code:56352
Mailing Address - Country:US
Mailing Address - Phone:320-256-4228
Mailing Address - Fax:320-256-7106
Practice Address - Street 1:525 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352
Practice Address - Country:US
Practice Address - Phone:320-256-4228
Practice Address - Fax:320-256-7106
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN261QM1300X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NA135OtherPREF ONE
35580OtherHEALTH PARTNERS
109966OtherUCARE
47A46CEOtherBCBS
98-01249OtherMEDICA
1068460007Medicare NSC
109966OtherUCARE