Healthcare Provider Details

I. General information

NPI: 1306867528
Provider Name (Legal Business Name): JEANINE L ROEMBACH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 05/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 4TH ST S
FARGO ND
58103-1929
US

IV. Provider business mailing address

100 4TH ST S
FARGO ND
58103-1929
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4141
  • Fax: 701-234-4137
Mailing address:
  • Phone: 701-234-4141
  • Fax: 701-234-4137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number7648
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier10028
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier792216700
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: