Provider Demographics
NPI:1366621534
Name:JEROME D. POLAND, M.D., LTD
Entity type:Organization
Organization Name:JEROME D. POLAND, M.D., LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-546-5108
Mailing Address - Street 1:1 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1665
Mailing Address - Country:US
Mailing Address - Phone:218-546-5108
Mailing Address - Fax:218-546-5736
Practice Address - Street 1:200 ELM ST N
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-7901
Practice Address - Country:US
Practice Address - Phone:320-532-3154
Practice Address - Fax:320-532-3111
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEROME D. POLAND, M.D., LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-24
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN566R0CROtherBLUE PLUS DISP
MN85038POOtherBLUE CROSS/BLUE SHIELD MN
MNCG9827OtherPALMETTO GBA
MNC08365Medicare PIN
MN85038POOtherBLUE CROSS/BLUE SHIELD MN