Provider Demographics
NPI:1376683003
Name:GERWE, JEREMY PAUL (MD)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:PAUL
Last Name:GERWE
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 1:3412 OFFICE PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959
Mailing Address - Country:US
Mailing Address - Phone:618-993-0404
Mailing Address - Fax:618-993-1717
Practice Address - Street 1:3412 OFFICE PARK DRIVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959
Practice Address - Country:US
Practice Address - Phone:618-993-0404
Practice Address - Fax:618-993-1717
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42607208000000X
IL036128431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200947990Medicaid
KY7100080980Medicaid
KYP400023999Medicare PIN