Provider Demographics
NPI:1144256843
Name:STALEY, JERRY T (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:T
Last Name:STALEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5728
Mailing Address - Country:US
Mailing Address - Phone:207-629-9488
Mailing Address - Fax:207-622-8796
Practice Address - Street 1:55 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5728
Practice Address - Country:US
Practice Address - Phone:207-629-9488
Practice Address - Fax:207-622-8796
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002023337208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00283188OtherRR MEDICARE
MOP00283188OtherRR MEDICARE