Healthcare Provider Details

I. General information

NPI: 1649247354
Provider Name (Legal Business Name): KENNETH J BREKER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9828 JENNY LN
SAINT JOSEPH MN
56374-9692
US

IV. Provider business mailing address

9828 JENNY LN
SAINT JOSEPH MN
56374-9692
US

V. Phone/Fax

Practice location:
  • Phone: 320-363-1127
  • Fax:
Mailing address:
  • Phone: 320-363-1127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number25968
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: