Basic Information
| Provider Information | |||||||||
| NPI: | 1184606501 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLER | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5166 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 393025166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6017039506 | ||||||||
| FaxNumber: | 6017033264 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354705410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056529575 | ||||||||
| FaxNumber: | 2056527979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 00008273 | AL | X | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0208X | 00008273 | AL | X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases |
ID Information
| ID | Type | State | Issuer | Description | 51020984 | 01 | BLUE CROSS OF AL | OTHER |