Provider Demographics
NPI:1235147729
Name:KROLL, JEROME (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:KROLL
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 1:2001 BLOOMINGTON AVENUE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3074
Mailing Address - Country:US
Mailing Address - Phone:612-301-3433
Mailing Address - Fax:612-627-4205
Practice Address - Street 1:2001 BLOOMINGTON AVENUE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3074
Practice Address - Country:US
Practice Address - Phone:612-301-3433
Practice Address - Fax:612-627-4205
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN230562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND81420Medicare UPIN
MN260002002Medicare ID - Type Unspecified