Provider Demographics
NPI:1710952999
Name:POOLE, JERRY MATTHEW (DPM)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MATTHEW
Last Name:POOLE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0917
Mailing Address - Country:US
Mailing Address - Phone:847-504-5000
Mailing Address - Fax:847-504-5015
Practice Address - Street 1:40 SKOKIE BLVD STE 520
Practice Address - Street 2:
Practice Address - City:NORTHBROOK
Practice Address - State:IL
Practice Address - Zip Code:60062-1601
Practice Address - Country:US
Practice Address - Phone:847-504-5000
Practice Address - Fax:847-504-5015
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI886-25213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1710952999Medicaid
WIP01615149OtherRAILROAD MEDICARE
ILP01743256OtherRAILROAD MEDICARE
ILF400339870Medicare PIN
WIK400267021Medicare PIN
ILP01743256OtherRAILROAD MEDICARE
207212Medicare ID - Type Unspecified