Basic Information
Provider Information | |||||||||
NPI: | 1700043114 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ARNOLD | ||||||||
FirstName: | JERRY | ||||||||
MiddleName: | GRAY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366081786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514145900 | ||||||||
FaxNumber: | 2512811169 | ||||||||
Practice Location | |||||||||
Address1: | 101 MEMORIAL HOSPITAL DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366081786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514145900 | ||||||||
FaxNumber: | 2512811153 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2008 | ||||||||
LastUpdateDate: | 05/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30151 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 102I119908 | 01 | AL | MEDICARE PTAN | OTHER | 128066 | 05 | AL |   | MEDICAID |