Basic Information
| Provider Information | |||||||||
| NPI: | 1821093881 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEYER | ||||||||
| FirstName: | JEROLD | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55435 TR 170 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403220332 | ||||||||
| FaxNumber: | 7406220335 | ||||||||
| Practice Location | |||||||||
| Address1: | 20265 EMERY RD | ||||||||
| Address2: | |||||||||
| City: | NORTH RANDALL | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441284122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4405239966 | ||||||||
| FaxNumber: | 2165842895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 02/25/2015 | ||||||||
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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 | 207Q00000X | 35042571 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0422859 | 05 | OH | MEDICAID |