Healthcare Provider Details

I. General information

NPI: 1952376527
Provider Name (Legal Business Name): KENNETH D ENGBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 COMO AVE
SAINT PAUL MN
55108
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-641-6200
  • Fax:
Mailing address:
  • Phone: 651-641-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number22842
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: