Provider Demographics
NPI:1326023060
Name:CARLISLE, JACK VICTOR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:VICTOR
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1601 GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8648
Mailing Address - Country:US
Mailing Address - Phone:218-326-5000
Mailing Address - Fax:218-326-1461
Practice Address - Street 1:1601 GOLF COURSE RD
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-8648
Practice Address - Country:US
Practice Address - Phone:218-326-5000
Practice Address - Fax:218-326-1461
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN31750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN462700800Medicaid
MNA94467Medicare UPIN
MN080011638Medicare ID - Type Unspecified