Provider Demographics
NPI:1184175812
Name:JERRY ORTHOPAEDIC INSTITUTE, PLLC
Entity type:Organization
Organization Name:JERRY ORTHOPAEDIC INSTITUTE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:JERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-987-9871
Mailing Address - Street 1:2009 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MI
Mailing Address - Zip Code:48079-4251
Mailing Address - Country:US
Mailing Address - Phone:810-329-7857
Mailing Address - Fax:
Practice Address - Street 1:600 FORT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3941
Practice Address - Country:US
Practice Address - Phone:810-987-9871
Practice Address - Fax:810-987-6070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2896292Medicaid
MI2896292Medicaid
MIA74822Medicare UPIN