Basic Information
| Provider Information | |||||||||
| NPI: | 1245266279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROOKS | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | DWYER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| Address2: | 1020 WEST BROADWAY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Practice Location | |||||||||
| Address1: | UMPHYSICIANS BROADWAY FAMILY MEDICINE | ||||||||
| Address2: | 1020 WEST BROADWAY | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123028200 | ||||||||
| FaxNumber: | 6123028275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 26201 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0144245 | 05 | MT | MEDICAID | 0549006 | 01 | MN | PREFERRED ONE | OTHER | 21592 | 01 | MN | ARAZ | OTHER | 01-20983 | 01 | MN | MEDICA CHOICE | OTHER | 109315 | 01 | MN | UCARE | OTHER | HP31006 | 01 | MN | HEALTHPARTNERS | OTHER | 251P1BR | 01 | MN | BCBS | OTHER | 34065600 | 05 | WI | MEDICAID | 0592204 | 05 | IA | MEDICAID | 511K0BR | 01 | MN | BCBS BFM | OTHER | A070 | 01 | MN | CHAMPUS | OTHER | 01-12519 | 01 | MN | MEDICA PRIMARY | OTHER | 01-21776 | 01 | MN | MEDICA CHOICE&PRIM BFM | OTHER |