Basic Information
Provider Information | |||||||||
NPI: | 1801878509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMENTEK | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | KATHRYN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DONOHOE | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 8674 | ||||||||
Address2: | 1230 E MAIN ST MANKATO CLINIC LTD | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560028674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076251811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1230 E MAIN ST | ||||||||
Address2: | MANKATO CLINIC | ||||||||
City: | MANKATO | ||||||||
State: | MN | ||||||||
PostalCode: | 560028674 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5076251811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 07/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 49051 | MN | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 001432575 | 05 | CT |   | MEDICAID | 135991 | 01 | MN | UCARE | OTHER | 295C2SM | 01 | MN | BCBS | OTHER | 0763177 | 05 | IA |   | MEDICAID | 277140100 | 05 | MN |   | MEDICAID | NA2951049098 | 01 | MN | PREFERRED ONE | OTHER | 12 03867 | 01 | MN | MEDICA | OTHER | 284 | 01 | MN | AMERICAS PPO | OTHER | HP75350 | 01 | MN | HEALTH PARTNERS | OTHER |