Provider Demographics
NPI:1578559563
Name:FERNLEY, JEFFREY E (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:E
Last Name:FERNLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10026 OLD OCEAN CITY BLVD
Mailing Address - Street 2:BUILDING ONE
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811
Mailing Address - Country:US
Mailing Address - Phone:410-641-9450
Mailing Address - Fax:410-641-9515
Practice Address - Street 1:9733 HEALTHWAY DRIVE
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811
Practice Address - Country:US
Practice Address - Phone:410-641-9450
Practice Address - Fax:410-641-9515
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3850174400000X
MDH0068754207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ79085901Medicaid
AZ79085901Medicaid
AZ75513Medicare ID - Type Unspecified