Provider Demographics
NPI:1164425781
Name:ETTERMAN, KENNETH E (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:E
Last Name:ETTERMAN
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 1:4570 CTY. HWY. 61
Mailing Address - Street 2:
Mailing Address - City:MOOSE LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55767
Mailing Address - Country:US
Mailing Address - Phone:218-485-4491
Mailing Address - Fax:218-485-4724
Practice Address - Street 1:206 MAIN ST. E.
Practice Address - Street 2:
Practice Address - City:HINCKLEY
Practice Address - State:MN
Practice Address - Zip Code:55037
Practice Address - Country:US
Practice Address - Phone:320-384-6618
Practice Address - Fax:320-384-6635
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23035207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN595790700Medicaid
MN595790700Medicaid
MND48546Medicare UPIN