Provider Demographics
NPI:1134169246
Name:BURROUGHS, JORY M (MD)
Entity type:Individual
Prefix:
First Name:JORY
Middle Name:M
Last Name:BURROUGHS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11207 STONEMILL FARMS CURV
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-5202
Mailing Address - Country:US
Mailing Address - Phone:651-337-0402
Mailing Address - Fax:
Practice Address - Street 1:300 STATE AVE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-6319
Practice Address - Country:US
Practice Address - Phone:507-333-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN46947207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN542471200Medicaid
MNI12427Medicare UPIN
MN542471200Medicaid