Provider Demographics
NPI:1679622237
Name:ST. CLOUD PODIATRY CLINIC, P.A.
Entity Type:Organization
Organization Name:ST. CLOUD PODIATRY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:LORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:320-253-7533
Mailing Address - Street 1:17 7TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4259
Mailing Address - Country:US
Mailing Address - Phone:320-253-7533
Mailing Address - Fax:320-654-8718
Practice Address - Street 1:17 7TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4259
Practice Address - Country:US
Practice Address - Phone:320-253-7533
Practice Address - Fax:320-654-8718
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN315213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNT65804Medicare UPIN
MN0271200001Medicare NSC