Provider Demographics
NPI:1780694943
Name:ROY, JERRY C (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:C
Last Name:ROY
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 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:1412 ELBA HWY
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36079-6020
Practice Address - Country:US
Practice Address - Phone:334-566-8822
Practice Address - Fax:334-808-8942
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH19476208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3116336Medicaid
NHT400632270OtherMEDICARE
G89341Medicare UPIN