Provider Demographics
NPI:1679541163
Name:LIERL, JERRY JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JOSEPH
Last Name:LIERL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:STE 177
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-331-3353
Mailing Address - Fax:859-331-3326
Practice Address - Street 1:20 MEDICAL VILLAGE DR
Practice Address - Street 2:STE. 177
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-5401
Practice Address - Country:US
Practice Address - Phone:859-331-3353
Practice Address - Fax:859-331-3326
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY20196207RI0011X, 207RC0000X
OH35050795207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64201965Medicaid
KYP00912930OtherRAILROAD MEDICARE
OH0626951Medicaid
KY00041001Medicare ID - Type Unspecified
OH0626951Medicaid
KYP400034316Medicare PIN
OHLI4037416Medicare ID - Type Unspecified