Provider Demographics
NPI:1760657407
Name:JERRY L. LIKE, D.O.
Entity Type:Organization
Organization Name:JERRY L. LIKE, D.O.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LIKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:812-983-4611
Mailing Address - Street 1:110 W. SYCAMORE
Mailing Address - Street 2:P.O. BOX 188
Mailing Address - City:ELBERFELD
Mailing Address - State:IN
Mailing Address - Zip Code:47613-0188
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 W. SYCAMORE ST.
Practice Address - Street 2:
Practice Address - City:ELBERFELD
Practice Address - State:IN
Practice Address - Zip Code:47613-0188
Practice Address - Country:US
Practice Address - Phone:812-983-4611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E45856Medicare UPIN
889010Medicare PIN