MEDICARE: MR. JERRY M LIDDELL DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0103X	Foot & Ankle Surgery Podiatrist	2005018735	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700872611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERRY M LIDDELL DPM

Provider Business Mailing Address
First Line	:	PO BOX 7412011
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60674-2011
Country	:	US
Telephone Number	:	314-747-4769
Fax Number	:	888-824-2176

Provider Business Practice Location Address
First Line	:	4901 FOREST PARK AVE
Second Line	:	DIV SURG ACCS PODIATRY, STE 420
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-1495
Country	:	US
Telephone Number	:	314-747-4769
Fax Number	:	888-824-2176

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	04/17/2025

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Directions to “ MR. JERRY M LIDDELL DPM” Practice Location

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