Active NPI
Kenneth E. Etterman, M.D.
- Family Medicine Physician
- Hinckley, MN
National Provider Identifier
1164425781
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- 23035
- Practice address
- 206 Main St. E.
Hinckley, MN 55037 - Phone
- (320) 384-6618
- Fax
- (320) 384-6635
- NPI assigned
- May 27, 2005
- Last updated
- Dec 4, 2012
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | 23035 | MN | Primary |
Addresses
Primary practice location
206 Main St. E.
Hinckley, MN 55037
Mailing address
4570 Cty. Hwy. 61
Moose Lake, MN 55767
Phone (218) 485-4491
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 595790700 | Medicaid | MN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1117152000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1354579200000",
"number": "1164425781",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4570 CTY. HWY. 61",
"city": "MOOSE LAKE",
"state": "MN",
"postal_code": "55767",
"telephone_number": "218-485-4491",
"fax_number": "218-485-4724"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "206 MAIN ST. E.",
"city": "HINCKLEY",
"state": "MN",
"postal_code": "55037",
"telephone_number": "320-384-6618",
"fax_number": "320-384-6635"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ETTERMAN",
"first_name": "KENNETH",
"middle_name": "E.",
"name_prefix": "Dr.",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2005-05-27",
"last_updated": "2012-12-04",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "MN",
"license": "23035",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "595790700",
"state": "MN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Hinckley, MN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 4, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.