Healthcare Provider Details

I. General information

NPI: 1659425114
Provider Name (Legal Business Name): CENTRACARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE CENTRACARE CLINIC INTERNAL MEDICINE
ST CLOUD MN
56303
US

IV. Provider business mailing address

PO BOX 735818
CHICAGO IL
60673-5818
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-4928
  • Fax:
Mailing address:
  • Phone: 320-229-4977
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL A BLAIR
Title or Position: SR VP & CFO
Credential:
Phone: 320-255-5665