Provider Demographics
NPI:1851388920
Name:MEDCENTRA LLC
Entity Type:Organization
Organization Name:MEDCENTRA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SISKA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-545-3006
Mailing Address - Street 1:225 SMITH AVE N
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2534
Mailing Address - Country:US
Mailing Address - Phone:651-288-5180
Mailing Address - Fax:651-288-5188
Practice Address - Street 1:225 SMITH AVE N
Practice Address - Street 2:SUITE 301
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2534
Practice Address - Country:US
Practice Address - Phone:651-288-5180
Practice Address - Fax:651-288-5188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24-4516Medicare ID - Type UnspecifiedCORF