Provider Demographics
NPI:1265445845
Name:JERRY L. WOOLUM, M.D., P.S.C.
Entity Type:Organization
Organization Name:JERRY L. WOOLUM, M.D., P.S.C.
Other - Org Name:WOOLUM & COMBS-WOOLUM, P.S.C.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WOOLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-337-0860
Mailing Address - Street 1:121 VIRGINIA AVENUE
Mailing Address - Street 2:SUITE F200
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977
Mailing Address - Country:US
Mailing Address - Phone:606-337-0860
Mailing Address - Fax:606-337-9956
Practice Address - Street 1:121 VIRGINIA AVENUE
Practice Address - Street 2:SUITE F200
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977
Practice Address - Country:US
Practice Address - Phone:606-337-0860
Practice Address - Fax:606-337-9956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65936379Medicaid
KY65936379Medicaid