Provider Demographics
NPI:1952333890
Name:MCENTIRE, JERRILL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRILL
Middle Name:LEE
Last Name:MCENTIRE
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:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:NC
Mailing Address - Zip Code:28762-0789
Mailing Address - Country:US
Mailing Address - Phone:828-668-7694
Mailing Address - Fax:
Practice Address - Street 1:26 SOUTH THOMASON STREET
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:NC
Practice Address - Zip Code:28762-0789
Practice Address - Country:US
Practice Address - Phone:828-668-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCC85424Medicare UPIN