Provider Demographics
NPI:1942276084
Name:JERRY, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:JERRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1221 PINE GROVE AVE
Mailing Address - Street 2:MCLAREN PORT HURON - EMERGENCY MEDICINE DEPARTMENT
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3511
Mailing Address - Country:US
Mailing Address - Phone:810-989-3300
Mailing Address - Fax:810-985-2671
Practice Address - Street 1:1221 PINE GROVE AVE
Practice Address - Street 2:MCLAREN PORT HURON - EMERGENCY MEDICINE DEPARTMENT
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3511
Practice Address - Country:US
Practice Address - Phone:810-989-3300
Practice Address - Fax:810-985-2671
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2014-09-04
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Provider Licenses
StateLicense IDTaxonomies
MI4301055524207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1942276084Medicaid
MI1942276084Medicaid