Provider Demographics
NPI:1356497150
Name:GENSMER, CHARLES OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:OWEN
Last Name:GENSMER
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 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:
Practice Address - Street 1:4050 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:763-236-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26057207RS0012X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN829802500Medicaid
MNH400128070Medicare PIN
MN829802500Medicaid
MN290000744Medicare PIN
MN411948038OtherHEALTH PARTNERS
MN1000521OtherPREFERRED ONE
MN290012150OtherRAILROAD MEDICARE
MN46B34GEOtherBCBS
MN290000283OtherWPS MEDICARE
MNA95916Medicare UPIN