Provider Demographics
NPI:1700378494
Name:KROLL, JOSHUA (DO)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:KROLL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:400 HOBART ST
Mailing Address - Street 2:C/O PAYER ENROLLMENT
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2331
Mailing Address - Country:US
Mailing Address - Phone:231-876-7807
Mailing Address - Fax:231-876-6121
Practice Address - Street 1:1400 MEDICAL CAMPUS DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7823
Practice Address - Country:US
Practice Address - Phone:231-935-8000
Practice Address - Fax:231-935-8099
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101023923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101023923OtherLICENSE