Healthcare Provider Details

I. General information

NPI: 1811036809
Provider Name (Legal Business Name): THEODORE MCMENOMY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 10TH ST W
SAINT PAUL MN
55102
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W STE 370
SAINT PAUL MN
55104-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-3000
  • Fax:
Mailing address:
  • Phone: 651-232-6905
  • Fax: 651-326-8170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number57429
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2005-0350
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number56538-20
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number51402
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: