Healthcare Provider Details

I. General information

NPI: 1467615294
Provider Name (Legal Business Name): ST. CLOUD HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2008
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N STE 201
SAINT CLOUD MN
56303-2253
US

IV. Provider business mailing address

1406 6TH AVE N
SAINT CLOUD MN
56303-1900
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-3761
  • Fax: 320-656-7009
Mailing address:
  • Phone: 320-229-3761
  • Fax: 320-656-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code276400000X
TaxonomySubstance Use Disorder Rehabilitation Hospital Unit
License Number803875 3 CDT
License Number StateMN

VIII. Authorized Official

Name: MR. MICHAEL A. BLAIR
Title or Position: SR. VICE PRESIDENT & CFO
Credential:
Phone: 320-255-5665