Provider Demographics
NPI:1942229661
Name:WITHROW, JERRY
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:WITHROW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9332 S TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-3108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9332 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-3108
Practice Address - Country:US
Practice Address - Phone:704-587-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC36635207Q00000X
NC27541207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988678Medicaid
NC080189817OtherMEDICARE RR
NC88678OtherNCBCBS
NC1942229661Medicaid
SC366357Medicaid
NCNC3467FMedicare PIN
NCNC3467GMedicare PIN
NC2281896AMedicare PIN
NC2281896Medicare PIN
NC8988678Medicaid
NCNC3467EMedicare PIN
NCNC3467DMedicare PIN
NC88678OtherNCBCBS
NCNC3467AMedicare PIN
NC2281896BMedicare PIN
NC080189817OtherMEDICARE RR
NC1942229661Medicaid
NCNC3467CMedicare PIN
NC2281896CMedicare PIN