Provider Demographics
NPI:1780660340
Name:MCLANE, JERRY THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:THOMAS
Last Name:MCLANE
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 1:1988 ROCKY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35243-1750
Mailing Address - Country:US
Mailing Address - Phone:205-969-3021
Mailing Address - Fax:
Practice Address - Street 1:915 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BESSEMER
Practice Address - State:AL
Practice Address - Zip Code:35022-6025
Practice Address - Country:US
Practice Address - Phone:205-481-8664
Practice Address - Fax:205-481-8665
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALC73739Medicare UPIN