Provider Demographics
NPI:1093744120
Name:FROELICH, JERRY WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WALTER
Last Name:FROELICH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE ST SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS, MMC 292
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455-0341
Mailing Address - Country:US
Mailing Address - Phone:612-626-3345
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE ST SE
Practice Address - Street 2:UNIV.OF MN PHYSICIANS, PWB FIRST FLOOR, CLINIC 1D
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0356
Practice Address - Country:US
Practice Address - Phone:612-273-6004
Practice Address - Fax:612-273-8459
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44437207U00000X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNHP34061OtherHEALTHPARTNERS
MN236323OtherARAZ
ND10387Medicaid
IA0571968Medicaid
MT0068000Medicaid
MN1029764OtherPREFERRED ONE
MN16-02032OtherMEDICA PRIMARY
MN16-02745OtherMEDICA CHOICE
MN170259OtherUCARE
SD7777470Medicaid
MN1029764OtherPREFERRED ONE
SD7777470Medicaid