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NPI Code Detail

MEDICARE: JOHN ROBERT HOLLERUD M.D.

MEDICARE: JOHN ROBERT HOLLERUD M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics Physician36159MN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1942317888
Entity Type Code : Individual
Provider Name (Legal Business Name) : JOHN ROBERT HOLLERUD M.D.
Provider Business Mailing Address
First Line : 11107 ULYSSES ST NE STE 100
Second Line :
City : BLAINE
State : MN
Zip : 55434-4264
Country : US
Telephone Number : 763-333-7733
Fax Number : 763-333-7711
Provider Business Practice Location Address
First Line : 11107 ULYSSES ST NE STE 100
Second Line :
City : BLAINE
State : MN
Zip : 55434-4264
Country : US
Telephone Number : 763-333-7733
Fax Number : 763-333-7711
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/24/2006
Last Update Date : 06/30/2021

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