Healthcare Provider Details

I. General information

NPI: 1356464689
Provider Name (Legal Business Name): JERRY W LIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E CHESTNUT ST # STREET6
LOUISVILLE KY
40202-1713
US

IV. Provider business mailing address

PO BOX 776879
CHICAGO IL
60677-6379
US

V. Phone/Fax

Practice location:
  • Phone: 502-583-3687
  • Fax: 502-588-7840
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberN0925
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number50410
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number0101253457
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License NumberN0925
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: