Provider Demographics
NPI:1154315075
Name:BROOKS, JEREMIAH HILTON III (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:HILTON
Last Name:BROOKS
Suffix:III
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:PO BOX 1798
Mailing Address - Street 2:
Mailing Address - City:MIDDLESBORO
Mailing Address - State:KY
Mailing Address - Zip Code:40965-3798
Mailing Address - Country:US
Mailing Address - Phone:606-248-2213
Mailing Address - Fax:606-248-5916
Practice Address - Street 1:3603 CUMBERLAND AVE
Practice Address - Street 2:
Practice Address - City:MIDDLESBORO
Practice Address - State:KY
Practice Address - Zip Code:40965-2613
Practice Address - Country:US
Practice Address - Phone:606-248-2213
Practice Address - Fax:606-248-5916
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY23313207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC75208Medicare UPIN
KY1509901Medicare ID - Type Unspecified