Provider Demographics
NPI:1730407586
Name:CENTRACARE HEALTH SYSTEM - MELROSE
Entity type:Organization
Organization Name:CENTRACARE HEALTH SYSTEM - MELROSE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT AND CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BLAIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-255-5665
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-256-4231
Mailing Address - Fax:320-256-4949
Practice Address - Street 1:525 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MN
Practice Address - Zip Code:56352-1043
Practice Address - Country:US
Practice Address - Phone:320-256-4231
Practice Address - Fax:320-256-4949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-04
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN243454Medicare Oscar/Certification