Healthcare Provider Details

I. General information

NPI: 1407818388
Provider Name (Legal Business Name): TIMOTHY GEORGE VEDDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N CENTRA CARE CLINIC
SAINT CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE N CENTRA CARE CLINIC
SAINT CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax:
Mailing address:
  • Phone: 320-252-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12652
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number56013
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56013
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: