Healthcare Provider Details

I. General information

NPI: 1487690996
Provider Name (Legal Business Name): ST CLOUD MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-8949
  • Fax: 320-202-0756
Mailing address:
  • Phone: 320-202-8949
  • Fax: 320-202-0756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER TACL
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 320-202-8949