Healthcare Provider Details

I. General information

NPI: 1285811612
Provider Name (Legal Business Name): CENTRAL MINNESOTA FOOT AND ANKLE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2008
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 STEARNS WAY SUITE 105
SAINT CLOUD MN
56303-4491
US

IV. Provider business mailing address

2025 STEARNS WAY SUITE 105
SAINT CLOUD MN
56303-4491
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-2963
  • Fax:
Mailing address:
  • Phone: 320-252-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number486
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number486
License Number StateMN

VIII. Authorized Official

Name: DR. GREGORY ROUW
Title or Position: VICE PRESIDENT
Credential: D.P.M.
Phone: 320-252-2963