Provider Demographics
NPI:1326342304
Name:JERALD M. FORD, M.D., PSC
Entity Type:Organization
Organization Name:JERALD M. FORD, M.D., PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-325-1200
Mailing Address - Street 1:PO BOX 2527
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2527
Mailing Address - Country:US
Mailing Address - Phone:606-325-1200
Mailing Address - Fax:606-324-9348
Practice Address - Street 1:617 23RD ST
Practice Address - Street 2:SUITE 415
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2880
Practice Address - Country:US
Practice Address - Phone:606-325-1200
Practice Address - Fax:606-324-9348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15865207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYC69118Medicare UPIN