Provider Demographics
NPI:1245281823
Name:BROCKMANN, KENT GREGORY (MD)
Entity type:Individual
Prefix:DR
First Name:KENT
Middle Name:GREGORY
Last Name:BROCKMANN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8673 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042
Mailing Address - Country:US
Mailing Address - Phone:651-209-9383
Mailing Address - Fax:651-209-9384
Practice Address - Street 1:8673 EAGLE POINT BLVD
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042
Practice Address - Country:US
Practice Address - Phone:651-209-9383
Practice Address - Fax:651-209-9384
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN445192084P0800X, 261QM0801X
WI48376-20261QM0850X
261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN087897900Medicaid
MN273L3BROtherBLUECROSS/BLUESHIELD MN
MN15-45530OtherMEDICA/UBH ID
MN087897900Medicaid
MN15-45530OtherMEDICA/UBH ID