Provider Demographics
NPI:1629274022
Name:JERRY MCLANE INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:JERRY MCLANE INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KELLY
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:205-424-5664
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:BESSEMER
Mailing Address - State:AL
Mailing Address - Zip Code:35021-0430
Mailing Address - Country:US
Mailing Address - Phone:205-424-5664
Mailing Address - Fax:205-424-1564
Practice Address - Street 1:1088 9TH AVE SW
Practice Address - Street 2:SUITE 106
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-4530
Practice Address - Country:US
Practice Address - Phone:205-424-5664
Practice Address - Fax:205-424-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC73739Medicare UPIN