Provider Demographics
NPI:1811036809
Name:MCMENOMY, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:MCMENOMY
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 1:1690 UNIVERSITY AVE W STE 370
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3723
Mailing Address - Country:US
Mailing Address - Phone:651-232-6905
Mailing Address - Fax:651-326-8170
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-232-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO57429207RP1001X
NM2005-0350207R00000X
WI56538-20390200000X
MN51402207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program