Provider Demographics
NPI:1366441362
Name:HENJUM, BRIAN A (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:HENJUM
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 1:4695 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9715
Mailing Address - Country:US
Mailing Address - Phone:952-442-7890
Mailing Address - Fax:952-442-7893
Practice Address - Street 1:13560 WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1850
Practice Address - Country:US
Practice Address - Phone:763-257-8100
Practice Address - Fax:763-257-8140
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN26247207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN125767600Medicaid
MN26247OtherMEDICAL LICENSE
MNA94104Medicare UPIN