Provider Demographics
NPI:1437249893
Name:KOENEMAN, KENNETH S (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:S
Last Name:KOENEMAN
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 1:420 DELAWARE ST SE MMC 394
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-626-6666
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:PWB FIRST FLOOR, CLINIC 1E
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-626-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46470208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN131340OtherUCARE
B715OtherCHAMPUS
MN692293OtherFAIRVIEW
MN19-00018OtherMEDICA-PRIMARY
MNHP40917OtherHEALTH PARTNERS
MN19-00591OtherMEDICA-CHOICE
MN1040762OtherPREFERRED ONE
MN455R5KOOtherBCBS
2162398OtherARAZ
MN19-00018OtherMEDICA-PRIMARY
MN692293OtherFAIRVIEW