Basic Information
| Provider Information | |||||||||
| NPI: | 1437250800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENNERSTROM | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396742 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 SOUTH CASCADE STREET | ||||||||
| Address2: | |||||||||
| City: | FERGUS FALLS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 565372813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187368000 | ||||||||
| FaxNumber: | 2187396742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 02/16/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 33413 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200383400A | 05 | IN | MEDICAID | 806646400 | 05 | ID | MEDICAID | HP27402 | 01 | MN | HEALTHPARTNERS | OTHER | 1008800 | 01 | MN | PREFERREDONE | OTHER | 01-14533 | 01 | MN | MEDICABLC | OTHER | 093007500 | 05 | MN | MEDICAID | 41091744413 | 05 | NE | MEDICAID | 109371 | 01 | MN | UCAREMN | OTHER | 232419 | 05 | OR | MEDICAID | 01-00794 | 01 | MN | MEDICAFFMG&WRC | OTHER | 80532VE | 01 | MN | BCBS | OTHER |