Provider Demographics
NPI:1871502500
Name:BEERENDS, JEROLD J (MD)
Entity Type:Individual
Prefix:
First Name:JEROLD
Middle Name:J
Last Name:BEERENDS
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:205 VALLEY AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5312
Practice Address - Country:US
Practice Address - Phone:262-338-1123
Practice Address - Fax:262-338-7684
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20959208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30104200Medicaid
WI462360402Medicare PIN
B51462Medicare UPIN
WI30104200Medicaid
WI019940010Medicare PIN