Provider Demographics
NPI:1013993401
Name:MINNESOTA STATE COLLEGES AND UNIVERSITIES
Entity Type:Organization
Organization Name:MINNESOTA STATE COLLEGES AND UNIVERSITIES
Other - Org Name:ST. CLOUD STATE UNIVERSITY MEDICAL CLINIC AND COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSCOATE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:OHMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-308-4872
Mailing Address - Street 1:720 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4442
Mailing Address - Country:US
Mailing Address - Phone:320-308-3191
Mailing Address - Fax:320-308-3192
Practice Address - Street 1:850 FIRST AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4442
Practice Address - Country:US
Practice Address - Phone:320-308-3191
Practice Address - Fax:320-308-3192
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MINNESOTA STATE COLLEGE AND UNIVERSITIES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-19
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1013993401Medicaid