Provider Demographics
NPI:1134280324
Name:PATRICK, KENT MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:KENT
Middle Name:MICHAEL
Last Name:PATRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:717 S STATE ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4469
Mailing Address - Country:US
Mailing Address - Phone:507-238-4949
Mailing Address - Fax:507-238-3377
Practice Address - Street 1:717 S STATE ST
Practice Address - Street 2:SUITE 900
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4469
Practice Address - Country:US
Practice Address - Phone:507-238-4949
Practice Address - Fax:507-238-3377
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC041516207X00000X
MN103500207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C415160Medicaid
MN154N4PAOtherBLUE CROSS BLUE SHIELD
A37619Medicare UPIN
CAA37619Medicare ID - Type Unspecified