Basic Information
| Provider Information | |||||||||
| NPI: | 1184098717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JRK MEDICALS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559035865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 4TH ST SE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559044717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 04/27/2016 | ||||||||
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| AuthorizedOfficialLastName: | GORDON | ||||||||
| AuthorizedOfficialFirstName: | ERIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 6302169514 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202K00000X | 47952 | MN | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Phlebology | 207RC0000X | 47952 | MN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 47952 | 01 | MN | MN MEDICAL LICENSE | OTHER |