Provider Demographics
NPI:1487690996
Name:ST CLOUD MEDICAL GROUP PA
Entity type:Organization
Organization Name:ST CLOUD MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TACL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:320-202-8949
Mailing Address - Street 1:251 COUNTY ROAD 120
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4872
Mailing Address - Country:US
Mailing Address - Phone:320-202-8949
Mailing Address - Fax:320-202-0756
Practice Address - Street 1:251 COUNTY ROAD 120
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4872
Practice Address - Country:US
Practice Address - Phone:320-202-8949
Practice Address - Fax:320-202-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN175710500Medicaid
MNC07627Medicare PIN
MN175710500Medicaid