Provider Demographics
NPI:1083785075
Name:BOYER, JERREL H (DO)
Entity Type:Individual
Prefix:
First Name:JERREL
Middle Name:H
Last Name:BOYER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 N HALSTED ST STE 509
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5194
Mailing Address - Country:US
Mailing Address - Phone:773-629-6666
Mailing Address - Fax:737-296-9999
Practice Address - Street 1:3000 N HALSTED ST STE 509
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5194
Practice Address - Country:US
Practice Address - Phone:773-629-6666
Practice Address - Fax:737-296-9999
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02714207T00000X
IL036-125876207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64034762Medicaid
H37934Medicare UPIN
KY64034762Medicaid