1700872611 NPI number — MR. JERRY M LIDDELL DPM

Table of content: MR. JERRY M LIDDELL DPM (NPI 1700872611)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700872611 NPI number — MR. JERRY M LIDDELL DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIDDELL
Provider First Name:
JERRY
Provider Middle Name:
M
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700872611
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60352
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63160-0352
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-747-4769
Provider Business Mailing Address Fax Number:
888-824-2176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4901 FOREST PARK AVE
Provider Second Line Business Practice Location Address:
DIV SURG ACCS PODIATRY, STE 420
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63108-1495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-747-4769
Provider Business Practice Location Address Fax Number:
888-824-2176
Provider Enumeration Date:
09/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  2005018735 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 307371203 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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