Provider Demographics
NPI:1013951185
Name:ADDERHOLT, JERRY GREGORY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:GREGORY
Last Name:ADDERHOLT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:426 EAST DOCTOR HICKS BLVD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-6625
Mailing Address - Country:US
Mailing Address - Phone:256-764-7721
Mailing Address - Fax:256-764-8589
Practice Address - Street 1:426 EAST DR.HICKS BLVD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-6625
Practice Address - Country:US
Practice Address - Phone:256-764-7721
Practice Address - Fax:256-764-8589
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL19765207T00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009999445Medicaid
ALF53145Medicare UPIN
AL009999445Medicaid