Provider Demographics
NPI:1255311866
Name:MCCRERY, JERRY E (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:E
Last Name:MCCRERY
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 1:1527 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-2537
Mailing Address - Country:US
Mailing Address - Phone:320-762-0399
Mailing Address - Fax:320-762-6847
Practice Address - Street 1:1527 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-2537
Practice Address - Country:US
Practice Address - Phone:320-762-0399
Practice Address - Fax:320-762-6847
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN022578174400000X
MN22578207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA009OtherCHAMPUS
MN0400552OtherMEDICA
MN738285500Medicaid
MN121118D277OtherUCARE
MN763172OtherAMERICA'S PPO
MNHP24911OtherHEALTH PARTNERS
MN1000248OtherPREFERRED ONE
MN31T05MCOtherBLUE SHIELD
MN1000248OtherPREFERRED ONE
MN121118D277OtherUCARE