Provider Demographics
NPI:1306867528
Name:ROEMBACH, JEANINE L (MD)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:L
Last Name:ROEMBACH
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 1:100 4TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-1929
Mailing Address - Country:US
Mailing Address - Phone:701-234-4141
Mailing Address - Fax:701-234-4137
Practice Address - Street 1:100 4TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1929
Practice Address - Country:US
Practice Address - Phone:701-234-4141
Practice Address - Fax:701-234-4137
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND76482084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND10028Medicaid
MN792216700Medicaid
NDN14517Medicare PIN
ND10028Medicaid
MN792216700Medicaid