Healthcare Provider Details

I. General information

NPI: 1699750570
Provider Name (Legal Business Name): JEROLD STEPHEN GREER LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 MONKEY RD
ELGIN TX
78621-5506
US

IV. Provider business mailing address

236 MONKEY RD
ELGIN TX
78621-5506
US

V. Phone/Fax

Practice location:
  • Phone: 432-935-1755
  • Fax: 512-285-4776
Mailing address:
  • Phone: 432-935-1755
  • Fax: 512-285-4776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA00074
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: