Provider Demographics
NPI:1114919024
Name:GRETEMAN, BRIAN J (DPM, PA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:GRETEMAN
Suffix:
Gender:M
Credentials:DPM, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 COON RAPIDS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2518
Mailing Address - Country:US
Mailing Address - Phone:763-422-0233
Mailing Address - Fax:763-422-9640
Practice Address - Street 1:3883 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2518
Practice Address - Country:US
Practice Address - Phone:763-422-0233
Practice Address - Fax:763-422-9640
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-17
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN 435213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
480032360OtherRR MEDICARE
1685548OtherARAZ
23283OtherGROUP HEALTH
27-25644OtherMEDICA
41-1984647OtherTRI-CARE
109919OtherCHOICE PLUS
1B746GROtherBC/BS (GROUP)
107452OtherU-CARE
9H364GROtherBC/BS (PIN)
HP17598OtherHEALTH PARTNERS
75928OtherHEALTH PARTNERS
873725800OtherMN MA
MN873725800Medicaid
961510781001OtherPREFERRED ONE
41-1984647OtherTRI-CARE
MN873725800Medicaid
480032360OtherRR MEDICARE