Basic Information
| Provider Information | |||||||||
| NPI: | 1366441362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENJUM | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4695 SHORELINE DR | ||||||||
| Address2: | |||||||||
| City: | SPRING PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553849715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524427890 | ||||||||
| FaxNumber: | 9524427893 | ||||||||
| Practice Location | |||||||||
| Address1: | 13560 WAYZATA BLVD | ||||||||
| Address2: | |||||||||
| City: | MINNETONKA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553051850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632578100 | ||||||||
| FaxNumber: | 7632578140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2005 | ||||||||
| LastUpdateDate: | 12/31/2008 | ||||||||
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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 | 26247 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 125767600 | 05 | MN | MEDICAID | 26247 | 01 | MN | MEDICAL LICENSE | OTHER |