Healthcare Provider Details

I. General information

NPI: 1588653331
Provider Name (Legal Business Name): LARRY DEAN KOBRIGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

IV. Provider business mailing address

1027 WASHINGTON AVE
DETROIT LAKES MN
56501-3409
US

V. Phone/Fax

Practice location:
  • Phone: 218-847-5611
  • Fax: 218-847-0891
Mailing address:
  • Phone: 218-847-5611
  • Fax: 218-847-0891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number37414
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: