Healthcare Provider Details

I. General information

NPI: 1194773671
Provider Name (Legal Business Name): PAUL JOHN VOLLMAR JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 10/19/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SKYLINE BLVD
CLOQUET MN
55720-1199
US

IV. Provider business mailing address

512 SKYLINE BLVD
CLOQUET MN
55720-1199
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-4641
  • Fax: 218-879-9167
Mailing address:
  • Phone: 218-879-4641
  • Fax: 218-879-9167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number48413
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number48413
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number23596
License Number StateNE
# 4
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number36476
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: