Provider Demographics
NPI:1821047317
Name:ST. CLOUD HOSPITAL
Entity Type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:CENTRACARE KIDNEY PROGRAM-PLAZA
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 1:2035 15TH ST N
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1738
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7009
Practice Address - Street 1:2035 15TH ST N
Practice Address - Street 2:SUITE 220
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1738
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:320-656-7009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331506261QE0700X
261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN883747300Medicaid
MN243528Medicare ID - Type Unspecified