MEDICARE: CENTRACARE CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	261QM1300X	Multi-Specialty Clinic/Center	MN
3	261QM1300X	Multi-Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NA139	OTHER	PREF ONE
3	35580	OTHER	HEALTH PARTNERS
4	110382	OTHER	UCARE
5	98-12146	OTHER	MEDICA
6	50A45CE	OTHER	BCBS
7	50A61CE	OTHER	BCBS

General Provider Information

NPI Number	:	1225030844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRACARE CLINIC

Provider Business Mailing Address
First Line	:	1200 6TH AVE N
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-2736
Country	:	US
Telephone Number	:	320-229-4977
Fax Number	:	320-654-3667

Provider Business Practice Location Address
First Line	:	1900 CENTRACARE CIRCLE
Second Line	:	CENTRACARE CLINIC-WOMEN & CHILDREN
City	:	ST CLOUD
State	:	MN
Zip	:	56303-5000
Country	:	US
Telephone Number	:	320-654-3630
Fax Number	:	320-654-3667

Authorized Official
Title or Position	:	SR VP & CFO
Name	:	MR. MICHAEL A BLAIR
Credential	:
Telephone Number	:	320-255-5665

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	07/21/2022

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Directions to “CENTRACARE CLINIC ” Practice Location

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