Provider Demographics
NPI:1750497574
Name:BEAN, JERRY NEAL (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:NEAL
Last Name:BEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:901 N MAIN ST
Mailing Address - Street 2:BOX 476
Mailing Address - City:TOMPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42167-1004
Mailing Address - Country:US
Mailing Address - Phone:270-487-0551
Mailing Address - Fax:270-487-0841
Practice Address - Street 1:901 N MAIN ST
Practice Address - Street 2:BOX 476
Practice Address - City:TOMPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42167-1004
Practice Address - Country:US
Practice Address - Phone:270-487-0551
Practice Address - Fax:270-487-0841
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2008-03-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY31175207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64311756Medicaid
G23559Medicare UPIN
KY1886601Medicare PIN