Healthcare Provider Details

I. General information

NPI: 1922059013
Provider Name (Legal Business Name): CENTRAL MINNESOTA ANESTHESIA, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1526 NORTHWAY DR
SAINT CLOUD MN
56303-1255
US

IV. Provider business mailing address

14700 28TH AVE N SUITE 20
PLYMOUTH MN
55447-4835
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-8385
  • Fax:
Mailing address:
  • Phone: 763-559-3779
  • Fax: 763-450-3986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARY L JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 320-251-8385