Healthcare Provider Details

I. General information

NPI: 1679541163
Provider Name (Legal Business Name): JERRY JOSEPH LIERL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL VILLAGE DR STE. 177
EDGEWOOD KY
41017-5401
US

IV. Provider business mailing address

20 MEDICAL VILLAGE DR STE 177
EDGEWOOD KY
41017-5401
US

V. Phone/Fax

Practice location:
  • Phone: 859-331-3353
  • Fax: 859-331-3326
Mailing address:
  • Phone: 859-331-3353
  • Fax: 859-331-3326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number20196
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35050795
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20196
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35050795
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: