Provider Demographics
NPI:1083688055
Name:AVERETT, JACK (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:AVERETT
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 1:833 SAINT VINCENTS DR
Mailing Address - Street 2:POB III SUITE 300
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35205-1606
Mailing Address - Country:US
Mailing Address - Phone:205-918-1471
Mailing Address - Fax:205-918-1470
Practice Address - Street 1:833 SAINT VINCENTS DR
Practice Address - Street 2:POB III SUITE 300
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-1606
Practice Address - Country:US
Practice Address - Phone:205-918-1471
Practice Address - Fax:205-918-1470
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD00006564207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D39320Medicare UPIN