MEDICARE: DR. JEROME ALLAN FAY O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2684	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2201029	OTHER	MN	MEDICA
2	140179	OTHER	MN	UCARE
3	32F04FA	OTHER	MN	BLUE CROSS/BLUE SHIELD
4	MEDICAL ASSISTANCE	OTHER	MN	MINNESOTA
5	40288	OTHER	MN	COLE MANAGED VISION

General Provider Information

NPI Number	:	1659335289
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEROME ALLAN FAY O.D.

Provider Business Mailing Address
First Line	:	1600 VIEWCREST CIR
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55306-5387
Country	:	US
Telephone Number	:	952-898-0513
Fax Number	:	651-646-3761

Provider Business Practice Location Address
First Line	:	1560 UNIVERSITY AVE W
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-3908
Country	:	US
Telephone Number	:	651-646-8889
Fax Number	:	651-646-3761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2006
Last Update Date	:	10/24/2011

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