Healthcare Provider Details

I. General information

NPI: 1184098717
Provider Name (Legal Business Name): JRK MEDICALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 VILLAGE CENTER DR
NORTH OAKS MN
55127-7848
US

IV. Provider business mailing address

PO BOX 5865
ROCHESTER MN
55903-5865
US

V. Phone/Fax

Practice location:
  • Phone: 651-765-8346
  • Fax:
Mailing address:
  • Phone: 702-453-3799
  • Fax: 702-453-5741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number47952
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number47952
License Number StateMN

VIII. Authorized Official

Name: ERIN GORDON
Title or Position: SUPERVISOR
Credential:
Phone: 630-216-9514