Healthcare Provider Details

I. General information

NPI: 1760047518
Provider Name (Legal Business Name): BRADEN ROBERT DASOVIC MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2019
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date: 12/16/2019
Reactivation Date: 02/11/2020

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax:
Mailing address:
  • Phone: 320-251-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number036164918
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number036164918
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084A2900X
TaxonomyNeurocritical Care Physician
License Number79397
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: