Provider Demographics
NPI:1043282817
Name:SIY, JEROME C (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:C
Last Name:SIY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:651-254-9673
Practice Address - Street 1:8170 33RD AVE S
Practice Address - Street 2:MC21110Q
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-4516
Practice Address - Country:US
Practice Address - Phone:651-254-9594
Practice Address - Fax:651-254-3662
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN42455207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN333630100Medicaid
110007151Medicare ID - Type Unspecified
H30024Medicare UPIN