Provider Demographics
NPI:1811763022
Name:RAUTENBERG, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:RAUTENBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2369 TART LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINO LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:55038-7730
Mailing Address - Country:US
Mailing Address - Phone:612-482-5900
Mailing Address - Fax:
Practice Address - Street 1:2369 TART LAKE RD
Practice Address - Street 2:
Practice Address - City:LINO LAKES
Practice Address - State:MN
Practice Address - Zip Code:55038-7730
Practice Address - Country:US
Practice Address - Phone:612-482-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-29
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies