Provider Demographics
NPI:1083668495
Name:NIX, JERRY DALE (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DALE
Last Name:NIX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:501 S SHARON AMITY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-0035
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-0035
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC94-00314207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC930067199OtherRR MEDICARE
NC89-62710Medicaid
NC62710OtherBCBSNC
SCN00314Medicaid
NC62710OtherBCBSNC
NC2197416CMedicare PIN