Basic Information
| Provider Information | |||||||||
| NPI: | 1356313480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNELL | ||||||||
| FirstName: | COLIN | ||||||||
| MiddleName: | W | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 S MN ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567161601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182819553 | ||||||||
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| Practice Location | |||||||||
| Address1: | 323 S MINNESOTA ST | ||||||||
| Address2: | |||||||||
| City: | CROOKSTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 567161601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182819553 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 01/13/2009 | ||||||||
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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 | 207XS0106X | 44689 | MN | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 812029300 | 05 | MN | MEDICAID |