Provider Demographics
NPI:1780635664
Name:JEROME D. POLAND MD LTD
Entity Type:Organization
Organization Name:JEROME D. POLAND MD LTD
Other - Org Name:DBA CROSBY EYE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
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 1:1 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1665
Practice Address - Country:US
Practice Address - Phone:218-546-5108
Practice Address - Fax:218-546-5736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2807770001332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN85038POOtherBLUE CROSS & BLUE SHIELD
MNCG9827OtherPALMETTO GBA
MN2807770001Medicare NSC
MNC08365Medicare ID - Type Unspecified
MN261527400Medicaid