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General NPI Number Information
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NPI Number | 1487690996
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Entity Type | Organization
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Legal Business Name | ST CLOUD MEDICAL GROUP PA
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Dates
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Enumeration Date | 06/22/2006
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Last Update Date | 10/06/2011
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Provider Practice Location Address
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Address Line | 251 COUNTY ROAD 120
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City | SAINT CLOUD
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State | MN
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Zip | 56303-4872
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Country | US
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Telephone | 320-202-8949
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Fax | 320-202-0756
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Provider Business Mailing Address
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Address Line | 251 COUNTY ROAD 120
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City | SAINT CLOUD
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State | MN
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Zip | 56303-4872
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Country | US
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Telephone | 320-202-8949
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Fax | 320-202-0756
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | CHRISTOPHER TACL
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Credential | MD
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Telephone | 320-202-8949
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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