Provider Demographics
NPI:1285813451
Name:JEROME D. POLAND, M.D., LTD
Entity Type:Organization
Organization Name:JEROME D. POLAND, M.D., LTD
Other - Org Name:CROSBY EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:D
Authorized Official - Last Name:POLAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:218-546-5108
Mailing Address - Street 1:1 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1665
Mailing Address - Country:US
Mailing Address - Phone:218-546-5108
Mailing Address - Fax:218-546-5736
Practice Address - Street 1:43500 MIGIZI DR
Practice Address - Street 2:
Practice Address - City:ONAMIA
Practice Address - State:MN
Practice Address - Zip Code:56359-2241
Practice Address - Country:US
Practice Address - Phone:320-532-4163
Practice Address - Fax:320-532-4354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEROME D. POLAND, M.D., LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-10-24
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
MN2807770001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN261527400Medicaid
MNCG9827OtherPALMETTO GBA
MN566R0CROtherBLUE PLUS DISP
MN85038POOtherBLUE CROSS/BLUE SHIELD MN
MNC08365Medicare PIN
MN261527400Medicaid