Provider Demographics
NPI:1861506263
Name:CENTRAL MINNESOTA SURGEONS LTD
Entity Type:Organization
Organization Name:CENTRAL MINNESOTA SURGEONS LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-251-5676
Mailing Address - Street 1:2000 23RD STREET SOUTH, SUITE 300
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-4768
Mailing Address - Country:US
Mailing Address - Phone:320-251-5676
Mailing Address - Fax:320-251-0623
Practice Address - Street 1:2000 23RD STREET SOUTH, SUITE 300
Practice Address - Street 2:
Practice Address - City:SARTELL
Practice Address - State:MN
Practice Address - Zip Code:56377-4768
Practice Address - Country:US
Practice Address - Phone:320-251-5676
Practice Address - Fax:320-251-0623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN488808100Medicaid
MN40020CEOtherBLUE SHIELD
MN488808100Medicaid