=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467464446
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY L WOOLUM MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2006
-----------------------------------------------------
Last Update Date | 02/14/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 HOSPITAL DR STE 2
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-7363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-4460
-----------------------------------------------------
Fax | 606-545-4469
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 HOSPITAL DR STE 2
-----------------------------------------------------
City | BARBOURVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40906-7363
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-545-4460
-----------------------------------------------------
Fax | 606-545-4469
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 15458
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------