Provider Demographics
NPI:1851355366
Name:GUANCIALE, JEROME MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:MATTHEW
Last Name:GUANCIALE
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-312-9802
Practice Address - Street 1:332 2ND AVE N
Practice Address - Street 2:
Practice Address - City:WAHPETON
Practice Address - State:ND
Practice Address - Zip Code:58075-4528
Practice Address - Country:US
Practice Address - Phone:701-642-7000
Practice Address - Fax:701-642-7055
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN70737208600000X
SC0393208600000X
NVDO2175208600000X
ND17750208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCE83181Medicare UPIN