Healthcare Provider Details

I. General information

NPI: 1942244736
Provider Name (Legal Business Name): JERRY MICHAEL HOLLINGSWORTH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 LEE RD. 248
SMITHS AL
36877
US

IV. Provider business mailing address

867 LEE RD 248 PO BOX 1417
SMITHS AL
36877
US

V. Phone/Fax

Practice location:
  • Phone: 334-291-8400
  • Fax: 334-291-8409
Mailing address:
  • Phone: 334-291-8400
  • Fax: 334-291-8409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberD0497
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: