Healthcare Provider Details

I. General information

NPI: 1720023112
Provider Name (Legal Business Name): JED GORLIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 PELHAM BLVD
SAINT PAUL MN
55114-1739
US

IV. Provider business mailing address

737 PELHAM BLVD
SAINT PAUL MN
55114-1739
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-7284
  • Fax: 651-332-7025
Mailing address:
  • Phone: 651-332-7284
  • Fax: 651-332-7025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License Number39988
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: