Healthcare Provider Details

I. General information

NPI: 1184606501
Provider Name (Legal Business Name): JERRY J. ELLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/20/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 N WASHINGTON ST
LIVINGSTON AL
35470-5410
US

IV. Provider business mailing address

PO BOX 5166
MERIDIAN MS
39302-5166
US

V. Phone/Fax

Practice location:
  • Phone: 205-652-9575
  • Fax: 205-652-7979
Mailing address:
  • Phone: 601-703-9506
  • Fax: 601-703-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number00008273
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number00008273
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: