Healthcare Provider Details

I. General information

NPI: 1154327286
Provider Name (Legal Business Name): JERRY H ALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 10/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

851 E 5TH ST STE 300
WASHINGTON MO
63090-3130
US

IV. Provider business mailing address

851 E 5TH ST STE 300
WASHINGTON MO
63090-3130
US

V. Phone/Fax

Practice location:
  • Phone: 636-390-8555
  • Fax: 636-390-9444
Mailing address:
  • Phone: 636-390-8555
  • Fax: 636-390-9444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD34565
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: