Provider Demographics
NPI:1417120809
Name:G. JERYL EVERIDGE, M.D.,P.C.
Entity Type:Organization
Organization Name:G. JERYL EVERIDGE, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:JERYL
Authorized Official - Last Name:EVERIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-324-0081
Mailing Address - Street 1:2022 10TH AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-3724
Mailing Address - Country:US
Mailing Address - Phone:706-324-0081
Mailing Address - Fax:706-324-1965
Practice Address - Street 1:2022 10TH AVE
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3724
Practice Address - Country:US
Practice Address - Phone:706-324-0081
Practice Address - Fax:706-324-1965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA14906174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00151841AMedicaid
GA00151841AMedicaid