Provider Demographics
NPI:1851399877
Name:PERRY, JACK R (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:PERRY
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:WALKER BAPTIST HOSPITAL
Mailing Address - Street 2:3400 HWY 78 E
Mailing Address - City:JASPER
Mailing Address - State:AL
Mailing Address - Zip Code:35501
Mailing Address - Country:US
Mailing Address - Phone:205-387-4000
Mailing Address - Fax:
Practice Address - Street 1:WALKER BAPTIST HOSPITAL
Practice Address - Street 2:3400 HWY 78 E
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501
Practice Address - Country:US
Practice Address - Phone:205-387-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2019-03-07
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
KY34733207R00000X
IL036.138175208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64347339Medicaid
KYP01183981OtherMEDICARE RAILROAD
KYK071242Medicare UPIN
KY64347339Medicaid
KY0921701Medicare PIN