1881696490 NPI number — CENTRACARE CLINIC

Table of content: (NPI 1881696490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881696490 NPI number — CENTRACARE CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRACARE CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRACARE CLINIC - NORTHWAY FAMILY MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1881696490
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 6TH AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLOUD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56303-2736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-229-4977
Provider Business Mailing Address Fax Number:
320-240-3131

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1555 NORTHWAY DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST CLOUD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-251-1775
Provider Business Practice Location Address Fax Number:
320-240-3131
Provider Enumeration Date:
08/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLAIR
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SR VP & CFO
Authorized Official Telephone Number:
320-255-5665

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NA131 . This is a "PREF ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 86D71CE . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 35580 . This is a "HEALTH PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 98-01806 . This is a "MEDICA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 110963 . This is a "UCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 990228700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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