Provider Demographics
NPI:1609867993
Name:JERBY, BRIAN LEROY (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:LEROY
Last Name:JERBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-333-1259
Mailing Address - Fax:704-333-0371
Practice Address - Street 1:1718 E 4TH ST
Practice Address - Street 2:SUITE 307
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3261
Practice Address - Country:US
Practice Address - Phone:704-333-1259
Practice Address - Fax:704-333-0371
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00264208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891195PMedicaid
NC891195PMedicaid
NC2270328Medicare PIN