Provider Demographics
NPI:1821029638
Name:ROSENDAHL, KIM J (PT)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:J
Last Name:ROSENDAHL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 S CAROL ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-1839
Mailing Address - Country:US
Mailing Address - Phone:208-287-9420
Mailing Address - Fax:208-287-9426
Practice Address - Street 1:1511 HIGHWAY 59 S
Practice Address - Street 2:SUITE A
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-3413
Practice Address - Country:US
Practice Address - Phone:218-681-0449
Practice Address - Fax:218-681-0490
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6635225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNP01328766OtherRAILROAD MEDICARE
MNH400133424OtherMEDICARE PROVIDER #
MNP10771Medicare UPIN
MN23474OtherNDBS #
MN6404178OtherMEDICA #
MN1935878OtherAMERICA'S PPO/ARAZ #
MNP10771Medicare UPIN
MNP00055269Medicare ID - Type UnspecifiedRR MEDICARE #
MN68G77ROOtherMNBS #