Healthcare Provider Details

I. General information

NPI: 1780635664
Provider Name (Legal Business Name): JEROME D. POLAND MD LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 3RD AVE NE
CROSBY MN
56441-1665
US

IV. Provider business mailing address

1 3RD AVE NE
CROSBY MN
56441-1665
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-5108
  • Fax: 218-546-5736
Mailing address:
  • Phone: 218-546-5108
  • Fax: 218-546-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2807770001
License Number StateMN

VIII. Authorized Official

Name: DR. JEROME D. POLAND
Title or Position: PRESIDENT
Credential: M.D.
Phone: 218-546-5108