Healthcare Provider Details

I. General information

NPI: 1831799238
Provider Name (Legal Business Name): JERRY GEORGE GREESON MED, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 WALKER AVE BLDG 5570
JBSA LACKLAND TX
78236-5632
US

IV. Provider business mailing address

24526 DREW GAP
SAN ANTONIO TX
78255-2284
US

V. Phone/Fax

Practice location:
  • Phone: 210-365-8316
  • Fax:
Mailing address:
  • Phone: 210-365-8316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAT0646
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: