Provider Demographics
NPI:1750595740
Name:SELIGMAN, JERRY WALTER (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:WALTER
Last Name:SELIGMAN
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 1:5811 GLEN PARK RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5980
Mailing Address - Country:US
Mailing Address - Phone:502-425-2364
Mailing Address - Fax:
Practice Address - Street 1:5811 GLEN PARK RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5980
Practice Address - Country:US
Practice Address - Phone:502-425-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY13947208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64139470Medicaid
KY64139470Medicaid
KYC74965Medicare UPIN