Healthcare Provider Details

I. General information

NPI: 1366621534
Provider Name (Legal Business Name): JEROME D. POLAND, M.D., LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 04/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 ELM ST N
ONAMIA MN
56359-7901
US

IV. Provider business mailing address

1 3RD AVE NE
CROSBY MN
56441-1665
US

V. Phone/Fax

Practice location:
  • Phone: 320-532-3154
  • Fax: 320-532-3111
Mailing address:
  • Phone: 218-546-5108
  • Fax: 218-546-5736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: KARIN M COOK
Title or Position: OFFICE MANAGER
Credential:
Phone: 218-546-5108