Healthcare Provider Details

I. General information

NPI: 1215254784
Provider Name (Legal Business Name): ROY KAGUMBA KIBERENGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-4762
  • Fax: 612-863-8425
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number055554
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number41888
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number290680
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number62855
License Number StateMN
# 5
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number62855
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: