Provider Demographics
NPI:1073938528
Name:GEDDIS, JERRON
Entity Type:Individual
Prefix:
First Name:JERRON
Middle Name:
Last Name:GEDDIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 S MAY ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-6052
Mailing Address - Country:US
Mailing Address - Phone:773-354-5421
Mailing Address - Fax:
Practice Address - Street 1:5421 S MAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-6052
Practice Address - Country:US
Practice Address - Phone:773-354-5421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-20
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILG32042068362343800000X, 343900000X, 347C00000X, 347E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No343800000XTransportation ServicesSecured Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL46-4868691Medicaid