Provider Demographics
NPI:1013104348
Name:CENTRACARE CLINIC
Entity Type:Organization
Organization Name:CENTRACARE CLINIC
Other - Org Name:CENTRACARE - BIG LAKE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP & CFO
Authorized Official - Prefix:
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 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-229-4977
Mailing Address - Fax:763-263-7338
Practice Address - Street 1:16830 198TH AVE NW
Practice Address - Street 2:CENTRACARE CLINIC - BIG LAKE
Practice Address - City:BIG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55309-4860
Practice Address - Country:US
Practice Address - Phone:763-263-7300
Practice Address - Fax:763-263-7338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRACARE CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-01
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
C07776Medicare PIN
MNC04829Medicare PIN