Provider Demographics
NPI:1437250800
Name:VENNERSTROM, ROBERT A (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:VENNERSTROM
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 1:712 SOUTH CASCADE STREET
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2813
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-739-6742
Practice Address - Street 1:712 SOUTH CASCADE STREET
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2813
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-739-6742
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN33413207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200383400AMedicaid
ID806646400Medicaid
MNHP27402OtherHEALTHPARTNERS
MN1008800OtherPREFERREDONE
MN01-14533OtherMEDICABLC
MN093007500Medicaid
NE41091744413Medicaid
MN109371OtherUCAREMN
OR232419Medicaid
MN01-00794OtherMEDICAFFMG&WRC
MN80532VEOtherBCBS
OR232419Medicaid
MN01-00794OtherMEDICAFFMG&WRC
MN01-14533OtherMEDICABLC
ID806646400Medicaid