Provider Demographics
NPI:1770532426
Name:ST. CLOUD HOSPITAL
Entity type:Organization
Organization Name:ST. CLOUD HOSPITAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:1555 NORTHWAY DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ST CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4913
Mailing Address - Country:US
Mailing Address - Phone:320-240-3157
Mailing Address - Fax:320-240-3143
Practice Address - Street 1:1555 NORTHWAY DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ST CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4913
Practice Address - Country:US
Practice Address - Phone:320-240-3157
Practice Address - Fax:320-240-3143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST CLOUD HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-09
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN331506261Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN616053100Medicaid
MN690000070OtherCENTRACARE LAB
MNRR MEDICAREOther690009424
MNC03318Medicare ID - Type Unspecified
MN690000071Medicare ID - Type UnspecifiedCENTRACARE LAB