Healthcare Provider Details

I. General information

NPI: 1649451873
Provider Name (Legal Business Name): ANIL KUMAR CHANGARATH VIJAYAN MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2007
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 320-240-2207
  • Fax: 320-240-7896
Mailing address:
  • Phone: 320-240-2207
  • Fax: 320-240-7896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.121030
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.125622
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number60177
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number036.125622
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number35.121030
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number60177
License Number StateMN
# 7
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number036.125622
License Number StateIL
# 8
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number35.121030
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number60177
License Number StateMN
# 10
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number036125622
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: