Provider Demographics
NPI:1831186691
Name:PAIGE, JERRY W (BS)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:W
Last Name:PAIGE
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346
Mailing Address - Country:US
Mailing Address - Phone:225-473-4719
Mailing Address - Fax:225-473-4719
Practice Address - Street 1:204 CLINIC DR
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346
Practice Address - Country:US
Practice Address - Phone:225-473-4719
Practice Address - Fax:225-473-4719
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-05
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA00457225100000X, 261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA650013713OtherRAILROAD MEDICARE
LA5S703Medicare ID - Type Unspecified
LA650013713OtherRAILROAD MEDICARE