1912016742 NPI number — DR. JERRY ALLEN LUCAS MD

Table of content: DR. JERRY ALLEN LUCAS MD (NPI 1912016742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912016742 NPI number — DR. JERRY ALLEN LUCAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCAS
Provider First Name:
JERRY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1912016742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
836 E 65TH ST STE 22
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAVANNAH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31405-4493
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-819-7171
Provider Business Mailing Address Fax Number:
912-691-9287

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5354 REYNOLDS ST STE 315
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAVANNAH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31405-6010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-354-2634
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2006

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: 207V00000X , with the licence number:  0101055788 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207VX0000X , with the licence number: 90992 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45748 . This is a "OPTIMA SENTARA ID#" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 160043283Q . This is a "RAILROAD MEDICARE ID#" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 541467765 . This is a "TAX ID#" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006210082 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20507 . This is a "VIRGINIA PREMIER ID #" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 952279 . This is a "AETNA ID#" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 90992 . This is a "STATE LICENSE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 5414523 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 271664 . This is a "ANTHEM BC/BS ID#" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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