Basic Information
| Provider Information | |||||||||
| NPI: | 1477963734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TU | ||||||||
| FirstName: | JERRY | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 S 2ND ST STE 2F | ||||||||
| Address2: | |||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171041612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172318772 | ||||||||
| FaxNumber: | 7172318435 | ||||||||
| Practice Location | |||||||||
| Address1: | 1575 BEAM AVE | ||||||||
| Address2: | |||||||||
| City: | MAPLEWOOD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512327000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2014 | ||||||||
| LastUpdateDate: | 05/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT206214 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 103292841 | 05 | PA | MEDICAID |