Provider Demographics
NPI:1376545160
Name:METCALF, JERRY T (CRNA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:T
Last Name:METCALF
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 FOX HOLW
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-2390
Mailing Address - Country:US
Mailing Address - Phone:815-748-8993
Mailing Address - Fax:
Practice Address - Street 1:626 BETHANY RD
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-4939
Practice Address - Country:US
Practice Address - Phone:815-748-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-255087207LP2900X
IL209-002136207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS01409Medicare UPIN
ILL90530Medicare PIN