Provider Demographics
NPI:1407912389
Name:JOHN RAYMOND FENYK, JR
Entity Type:Organization
Organization Name:JOHN RAYMOND FENYK, JR
Other - Org Name:MIDWEST DERMATOLOTY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:SELVIG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-545-8614
Mailing Address - Street 1:5647 DULUTH ST
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4054
Mailing Address - Country:US
Mailing Address - Phone:763-545-8614
Mailing Address - Fax:763-545-1935
Practice Address - Street 1:5647 DULUTH ST
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55422-4054
Practice Address - Country:US
Practice Address - Phone:763-545-8614
Practice Address - Fax:763-545-1935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23247207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN716001OtherPREFERRED ONE
MN04440FEOtherBCBS
MN384OtherHEALTH PARTNERS
MN03-03331OtherMEDICA CHOICE
MN03-00003OtherMEDICA PRIMARY
MN04440FEOtherBCBS
MNC04100Medicare ID - Type UnspecifiedMEDICARE
MN=========001OtherCHAMPUS