Provider Demographics
NPI:1720045073
Name:CENTRACARE HEALTH SYSTEM - MELROSE
Entity Type:Organization
Organization Name:CENTRACARE HEALTH SYSTEM - MELROSE
Other - Org Name:CENTRACARE HEALTH - MELROSE HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT AND 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:
Mailing Address - Fax:
Practice Address - Street 1:525 W. MAIN STREET
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352-1071
Practice Address - Country:US
Practice Address - Phone:320-256-4231
Practice Address - Fax:320-256-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN330997282NC0060X
MN347139282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN06374750Medicaid
MN241330Medicare ID - Type Unspecified