1184175812 NPI number — JERRY ORTHOPAEDIC INSTITUTE, PLLC

Table of content: (NPI 1184175812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184175812 NPI number — JERRY ORTHOPAEDIC INSTITUTE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERRY ORTHOPAEDIC INSTITUTE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1184175812
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2009 RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT CLAIR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48079-4251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-329-7857
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 FORT ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PORT HURON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48060-3941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-987-9871
Provider Business Practice Location Address Fax Number:
810-987-6070
Provider Enumeration Date:
10/18/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JERRY
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
810-987-9871

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2896292 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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