Healthcare Provider Details

I. General information

NPI: 1538369343
Provider Name (Legal Business Name): JERRY ALLEN SPIVEY JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 02/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 FOUNDERS ROW
GREENSBORO GA
30642
US

IV. Provider business mailing address

PO BOX 80883
ATHENS GA
30608-0883
US

V. Phone/Fax

Practice location:
  • Phone: 706-433-0723
  • Fax: 706-549-7558
Mailing address:
  • Phone: 706-549-8114
  • Fax: 706-549-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number065063
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number065063
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number65063
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number65063
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: