Provider Demographics
NPI:1184847659
Name:TALLEY, JEREMY SHAUN (DO)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:SHAUN
Last Name:TALLEY
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:PO BOX 19
Mailing Address - Street 2:
Mailing Address - City:HERMANN
Mailing Address - State:MO
Mailing Address - Zip Code:65041-0019
Mailing Address - Country:US
Mailing Address - Phone:573-486-2118
Mailing Address - Fax:573-486-3533
Practice Address - Street 1:1714 WEIN ST
Practice Address - Street 2:
Practice Address - City:HERMANN
Practice Address - State:MO
Practice Address - Zip Code:65041-1571
Practice Address - Country:US
Practice Address - Phone:573-486-2118
Practice Address - Fax:573-486-3533
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007006309207P00000X, 207Q00000X
IL036.117295207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine