Provider Demographics
NPI:1538192133
Name:ROREM, BRUCE A (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:ROREM
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 1:1630 ANDERSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2946
Mailing Address - Country:US
Mailing Address - Phone:612-270-8094
Mailing Address - Fax:
Practice Address - Street 1:1630 ANDERSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2946
Practice Address - Country:US
Practice Address - Phone:612-270-8094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26460207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080015602Medicare Oscar/Certification
MNA02586Medicare UPIN