Provider Demographics
NPI:1356313480
Name:FENNELL, COLIN W
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:W
Last Name:FENNELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 S MN ST
Mailing Address - Street 2:
Mailing Address - City:CROOKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1601
Mailing Address - Country:US
Mailing Address - Phone:218-281-9553
Mailing Address - Fax:
Practice Address - Street 1:323 S MINNESOTA ST
Practice Address - Street 2:
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716-1601
Practice Address - Country:US
Practice Address - Phone:218-281-9553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44689207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN812029300Medicaid
MN200002119Medicare PIN
MNF47056Medicare UPIN