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General NPI Number Information
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NPI Number | 1821257593
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Entity Type | Organization
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Legal Business Name | JERROL NOLLER MD LTD
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Dates
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Enumeration Date | 06/06/2008
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Last Update Date | 06/06/2008
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Provider Practice Location Address
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Address Line | 3863 COON RAPIDS BLVD NW
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City | COON RAPIDS
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State | MN
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Zip | 55433-2518
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Country | US
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Telephone | 763-433-8300
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Fax | 763-433-8308
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Provider Business Mailing Address
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Address Line | 1416 OAKWOOD DR
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City | ANOKA
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State | MN
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Zip | 55303-2747
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Country | US
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Telephone | 763-433-8300
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Fax | 763-433-8308
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JERROL JAY NOLLER
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Credential | MD
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Telephone | 763-427-6897
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 23068
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License Number State | MN
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