Provider Demographics
NPI:1114985454
Name:KOHLMAN-PETRICK, JOELLEN (MD)
Entity Type:Individual
Prefix:
First Name:JOELLEN
Middle Name:
Last Name:KOHLMAN-PETRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 S CASCADE ST
Mailing Address - Street 2:
Mailing Address - City:FERGUS FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56537-2913
Mailing Address - Country:US
Mailing Address - Phone:218-736-8000
Mailing Address - Fax:218-739-6718
Practice Address - Street 1:712 S CASCADE ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2913
Practice Address - Country:US
Practice Address - Phone:218-736-8000
Practice Address - Fax:218-739-6718
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN48295207R00000X
ND12070207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND16483Medicaid
ND16483Medicaid
NDN717177Medicare PIN