Provider Demographics
NPI:1174375760
Name:PETER S JEROME MD PLLC
Entity type:Organization
Organization Name:PETER S JEROME MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:JEROME
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-492-9802
Mailing Address - Street 1:350 BOWDEN LN
Mailing Address - Street 2:
Mailing Address - City:COLDSPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77331-9240
Mailing Address - Country:US
Mailing Address - Phone:469-492-9802
Mailing Address - Fax:
Practice Address - Street 1:350 BOWDEN LN
Practice Address - Street 2:
Practice Address - City:COLDSPRING
Practice Address - State:TX
Practice Address - Zip Code:77331-9240
Practice Address - Country:US
Practice Address - Phone:469-492-9802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX393948003Medicaid