Provider Demographics
NPI:1154509073
Name:GARY JENISON MD, PHD
Entity Type:Organization
Organization Name:GARY JENISON MD, PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGEER
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:JENISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-779-2233
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-0105
Mailing Address - Country:US
Mailing Address - Phone:740-779-2233
Mailing Address - Fax:740-779-2234
Practice Address - Street 1:80 STAR DR
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-9583
Practice Address - Country:US
Practice Address - Phone:740-779-2233
Practice Address - Fax:740-779-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-01
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35069046207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9309741Medicare PIN