NPIMap

Organization Active NPI

Centracare Clinic

Doing business as CentraCare - Big Lake Clinic

  • Multi-Specialty Clinic/Center
  • Big Lake, MN
National Provider Identifier
1013104348
Registry record updated Nov 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
CENTRACARE CLINIC
Doing business as
CentraCare - Big Lake Clinic
Practice address
16830 198TH Ave NW
Centracare Clinic - Big Lake
Big Lake, MN 55309-4860
Phone
(763) 263-7300
Fax
(763) 263-7338
NPI assigned
Oct 1, 2007
Last updated
Nov 19, 2020By the provider in NPPES
Organization subpart
Yes
Parent organization
CENTRACARE CLINICAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Nov 19, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Michael A Blair
Title
Sr VP & Cfo
Phone
(320) 255-5665

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X Primary
Durable Medical Equipment & Medical Supplies 332B00000X

Addresses

Primary practice location

16830 198TH Ave NW
Centracare Clinic - Big Lake
Big Lake, MN 55309-4860

Mailing address

1200 6TH Ave N
Saint Cloud, MN 56303-2736
Phone (320) 229-4977

Other names 1

  • CentraCare - Big Lake Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20031105000293 MN Part B Supplier - Clinic/Group Practice 2466363395 Receives reassigned benefits from 1,127 practitioners
29 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
O20141010001588 MN DME Supplier - Physician - General Practice 2466363395 1 other NPI on this enrollment
Practice locations: Big Lake, MN

Other NPIs with the same Medicare PAC ID 13

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

View all 13

Other NPIs on the same Medicare enrollment 26

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 26

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D1080211Centracare - Big Lake16830 198TH Ave NW, Big Lake, MN 55309Certificate of waiverFeb 28, 2027

National Provider Directory

National Provider Directory
Tax ID family
Centracare Clinic - Long Prairie12 organizations share this tax ID, including this one
Part of
Centracare Clinic - Long Prairie

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Locations

161 Glen St
Ste 101
Foley, MN 56329
Phone (320) 656-7128

1209 Sandy Ln
Monticello, MN 55362
Phone (763) 295-4856

1725 Pine Cone Rd S
Ste 101
Sartell, MN 56377
Phone (320) 656-7129

Practitioners & affiliated clinicians

Practitioners 54

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 54

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1191196800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605744000000",
    "number": "1013104348",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1200 6TH AVE N",
            "city": "SAINT CLOUD",
            "state": "MN",
            "postal_code": "563032736",
            "telephone_number": "320-229-4977",
            "fax_number": "763-263-7338"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "16830 198TH AVE NW",
            "address_2": "CENTRACARE CLINIC - BIG LAKE",
            "city": "BIG LAKE",
            "state": "MN",
            "postal_code": "553094860",
            "telephone_number": "763-263-7300",
            "fax_number": "763-263-7338"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRACARE CLINIC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTRACARE CLINIC",
        "enumeration_date": "2007-10-01",
        "last_updated": "2020-11-19",
        "certification_date": "2020-11-19",
        "status": "A",
        "authorized_official_last_name": "BLAIR",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "SR VP & CFO",
        "authorized_official_telephone_number": "320-255-5665"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "CentraCare - Big Lake Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Big Lake, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.