Provider Demographics
NPI:1538157805
Name:ST CLOUD EYE CLINIC PA
Entity type:Organization
Organization Name:ST CLOUD EYE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEFOREST
Authorized Official - Middle Name:EVERTON
Authorized Official - Last Name:STARKEY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:320-251-1432
Mailing Address - Street 1:2055 15TH ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1747
Mailing Address - Country:US
Mailing Address - Phone:320-251-1432
Mailing Address - Fax:320-251-7122
Practice Address - Street 1:2055 15TH ST N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1747
Practice Address - Country:US
Practice Address - Phone:320-251-1432
Practice Address - Fax:320-251-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54575LAOtherBLUE CROSS
C01527OtherRAILROAD MEDICARE
MN221523300Medicaid
MN54575LAOtherBLUE CROSS