Provider Demographics
NPI:1356464689
Name:LIN, JERRY W (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:LIN
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:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6379
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # STREET6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-583-3687
Practice Address - Fax:502-588-7840
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0925207Y00000X, 207YX0901X
VA0101253457207YX0901X
KY50410207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YX0901XAllopathic & Osteopathic PhysiciansOtolaryngologyOtology & Neurotology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX214396801Medicaid
KY7100478670Medicaid
TXTXB105547Medicare PIN
KY7100478670Medicaid