Provider Demographics
NPI:1285811612
Name:CENTRAL MINNESOTA FOOT AND ANKLE PLLC
Entity type:Organization
Organization Name:CENTRAL MINNESOTA FOOT AND ANKLE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROUW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:320-252-2963
Mailing Address - Street 1:2025 STEARNS WAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4491
Mailing Address - Country:US
Mailing Address - Phone:320-252-2963
Mailing Address - Fax:
Practice Address - Street 1:2025 STEARNS WAY
Practice Address - Street 2:SUITE 105
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4491
Practice Address - Country:US
Practice Address - Phone:320-252-2963
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-29
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN486213ES0103X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6197260001Medicare NSC