Healthcare Provider Details

I. General information

NPI: 1639959331
Provider Name (Legal Business Name): MADISON JO THRALOW PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 W SAINT GERMAIN ST
SAINT CLOUD MN
56301-6280
US

IV. Provider business mailing address

31019 GOLDFINCH LN
SAINT CLOUD MN
56301-7403
US

V. Phone/Fax

Practice location:
  • Phone: 320-259-4151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number13232
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: