Provider Demographics
NPI:1013996032
Name:PENKHUS, STEPHEN D (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:D
Last Name:PENKHUS
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:PO BOX 8674
Mailing Address - Street 2:123 E MAIN ST
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN22584207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
160025570OtherRR MEDICARE
MN688705800Medicaid
MNHP25860OtherHEALTH PARTNERS
MN115550OtherUCARE
MN771902OtherAMERICAS PPO
41084933956001C059OtherCHAMPUS
MN0702739OtherMEDICA
MN41497PEOtherBCBS
IA928614Medicaid
MNNA2951023851OtherPREFERRED ONE
MN0702739OtherMEDICA
D80084Medicare UPIN