MEDICARE: DR. LARRY BRYAN JENNINGS DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	R2480	AR

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00014273	OTHER	AR	RAILROAD MEDICARE PIN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	52660	OTHER	AR	BLUE CROSS AR
3	52660B477	OTHER	AR	BLUE CROSS ARKANSAS

General Provider Information

NPI Number	:	1750386553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARRY BRYAN JENNINGS DO

Provider Business Mailing Address
First Line	:	PO BOX 1060
Second Line	:
City	:	MARSHALL
State	:	AR
Zip	:	72650-1060
Country	:	US
Telephone Number	:	870-448-5733
Fax Number	:	870-448-5736

Provider Business Practice Location Address
First Line	:	2263 HIGHWAY 65 NORTH
Second Line	:
City	:	MARSHALL
State	:	AR
Zip	:	72650-1060
Country	:	US
Telephone Number	:	870-448-5733
Fax Number	:	870-448-3392

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	03/10/2008

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