Healthcare Provider Details

I. General information

NPI: 1942276902
Provider Name (Legal Business Name): PATRICK MICHAEL LALLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 03/27/2023
Certification Date: 03/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVENUE NORTH CENTRACARE CLINIC RIVER CAMPUS PALLIATIVE CARE
ST CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVENUE NORTH CENTRACARE CLINIC RIVER CAMPUS PALLIATIVE CARE
ST CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-656-7117
  • Fax: 320-255-5810
Mailing address:
  • Phone: 320-656-7117
  • Fax: 320-255-5810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23382
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number23382
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: