Healthcare Provider Details

I. General information

NPI: 1962493643
Provider Name (Legal Business Name): EITAN MEDINI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRA CARE CIR #1600 CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY
ST CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRA CARE CIR #1600 CENTRA CARE CLINIC HEALTH PLAZA / RADIATION ONCOLOGY
ST CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4901
  • Fax: 320-229-5160
Mailing address:
  • Phone: 320-229-4901
  • Fax: 320-229-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number21866
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: