Provider Demographics
NPI:1184606501
Name:ELLER, JERRY J (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:J
Last Name:ELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5166
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5166
Mailing Address - Country:US
Mailing Address - Phone:601-703-9506
Mailing Address - Fax:601-703-3264
Practice Address - Street 1:1221 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:AL
Practice Address - Zip Code:35470-5410
Practice Address - Country:US
Practice Address - Phone:205-652-9575
Practice Address - Fax:205-652-7979
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00008273208000000X, 2080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
51020984OtherBLUE CROSS OF AL
C76652Medicare UPIN