Healthcare Provider Details

I. General information

NPI: 1366441362
Provider Name (Legal Business Name): BRIAN A HENJUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 12/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13560 WAYZATA BLVD
MINNETONKA MN
55305-1850
US

IV. Provider business mailing address

4695 SHORELINE DR
SPRING PARK MN
55384-9715
US

V. Phone/Fax

Practice location:
  • Phone: 763-257-8100
  • Fax: 763-257-8140
Mailing address:
  • Phone: 952-442-7890
  • Fax: 952-442-7893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26247
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: