Provider Demographics
NPI:1063483378
Name:THOMAS, JERILL (MD,)
Entity Type:Individual
Prefix:
First Name:JERILL
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 5TH AVE E
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-7419
Mailing Address - Country:US
Mailing Address - Phone:205-348-1770
Mailing Address - Fax:205-348-5145
Practice Address - Street 1:850 5TH AVE E
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7419
Practice Address - Country:US
Practice Address - Phone:205-348-1770
Practice Address - Fax:205-348-5145
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL22507207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009981485Medicaid
AL009981485Medicaid
AL000055805Medicare ID - Type Unspecified
ALG88499Medicare UPIN