Healthcare Provider Details

I. General information

NPI: 1932273349
Provider Name (Legal Business Name): MARK STANLEY MATTHIAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 04/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CENTRACARE CIRCLE SUITE 2400
ST. CLOUD MN
56303-5000
US

IV. Provider business mailing address

1900 CENTRACARE CIRCLE SUITE 2400
ST. CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-229-5171
  • Fax: 320-229-5171
Mailing address:
  • Phone: 320-229-5099
  • Fax: 320-229-5171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number33585
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: