1811215460 NPI number — MERIDIAN FAMILY MEDICAL ASSOCIATES PLLC

Table of content: JILL EVELYN JERTSON M.D. (NPI 1952388019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811215460 NPI number — MERIDIAN FAMILY MEDICAL ASSOCIATES PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MERIDIAN FAMILY MEDICAL ASSOCIATES 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:
1811215460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3333 BAYSHORE BLVD
Provider Second Line Business Mailing Address:
250
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77504-1952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-400-4779
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3333 BAYSHORE BLVD
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77504-1961
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-400-4779
Provider Business Practice Location Address Fax Number:
713-344-0738
Provider Enumeration Date:
05/06/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BADU
Authorized Official First Name:
STEPHANIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER/FNP
Authorized Official Telephone Number:
914-400-4779

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  735840 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: 735840 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0300X , with the licence number: 735840 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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