Provider Demographics
NPI:1386655462
Name:PURVIS, JERRY GAINES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:GAINES
Last Name:PURVIS
Suffix:JR
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 1:5034 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BLOOMFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:43103-1018
Mailing Address - Country:US
Mailing Address - Phone:740-983-8346
Mailing Address - Fax:740-983-6600
Practice Address - Street 1:5034 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMFIELD
Practice Address - State:OH
Practice Address - Zip Code:43103-1018
Practice Address - Country:US
Practice Address - Phone:740-983-8346
Practice Address - Fax:740-983-6600
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-0726-P174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2297232Medicaid
OH2297232Medicaid
OHG66633Medicare UPIN