Healthcare Provider Details

I. General information

NPI: 1386837896
Provider Name (Legal Business Name): JERRY STEPHEN KROLL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5445 MERIDIAN MARKS RD NE SUITE 250
ATLANTA GA
30342-4763
US

IV. Provider business mailing address

5445 MERIDIAN MARKS RD NE STE 250
ATLANTA GA
30342-4767
US

V. Phone/Fax

Practice location:
  • Phone: 404-255-1933
  • Fax: 404-256-7924
Mailing address:
  • Phone: 404-255-1933
  • Fax: 404-256-7924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number062735
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: