Provider Demographics
NPI:1821257593
Name:JERROL NOLLER MD LTD
Entity Type:Organization
Organization Name:JERROL NOLLER MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERROL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:NOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:763-427-6897
Mailing Address - Street 1:1416 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2747
Mailing Address - Country:US
Mailing Address - Phone:763-433-8300
Mailing Address - Fax:763-433-8308
Practice Address - Street 1:3863 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2518
Practice Address - Country:US
Practice Address - Phone:763-433-8300
Practice Address - Fax:763-433-8308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN23068261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN774888400Medicaid
110008247Medicare PIN