Provider Demographics
NPI:1578564753
Name:MYRDA, JERRY (DO)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:MYRDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2350 ROYAL BLVD SUITE 300
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-4719
Mailing Address - Country:US
Mailing Address - Phone:847-742-3120
Mailing Address - Fax:847-742-4021
Practice Address - Street 1:2350 ROYAL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-4718
Practice Address - Country:US
Practice Address - Phone:847-742-3120
Practice Address - Fax:847-742-4021
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036110352207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI14914Medicare UPIN