Basic Information
| Provider Information | |||||||||
| NPI: | 1902874662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HANCOCK | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | 1314 EAST WALNUT STREET | ||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122542760 | ||||||||
| FaxNumber: | 8122578602 | ||||||||
| Practice Location | |||||||||
| Address1: | 1402 GRAND AVENUE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122546696 | ||||||||
| FaxNumber: | 8122547934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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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 | 02000363A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000000094084 | 01 | IN | ANTHEM | OTHER | CG3197 | 01 | IN | MEDICARE RAILROAD GROUP | OTHER |