Healthcare Provider Details

I. General information

NPI: 1962723825
Provider Name (Legal Business Name): GAVIN PATRICK MEANY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 12/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 6TH AVENUE NORTH ST. CLOUD HOSPITAL
ST. CLOUD MN
56303-1901
US

IV. Provider business mailing address

1900 CENTRACARE CIR # 2475 CENTRACARE HEALTH PLAZA
SAINT CLOUD MN
56303-5000
US

V. Phone/Fax

Practice location:
  • Phone: 320-251-2700
  • Fax: 320-229-5109
Mailing address:
  • Phone: 320-229-5199
  • Fax: 320-229-5109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number55711
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: