Provider Demographics
NPI:1235101171
Name:EIDEM, JORI L (PA)
Entity Type:Individual
Prefix:
First Name:JORI
Middle Name:L
Last Name:EIDEM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JORI
Other - Middle Name:L
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-284-2511
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0001
Practice Address - Country:US
Practice Address - Phone:507-284-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-04
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9884363A00000X
WI1967-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
MNP00996318OtherRAILROAD MEDICARE
MN824682300Medicaid
MN970003498Medicare PIN
MN970002897Medicare PIN
MN824682300Medicaid
MN970003499Medicare PIN