Provider Demographics
NPI:1144312869
Name:BEASLEY, JERRY STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:STEPHEN
Last Name:BEASLEY
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 1:1119 E COLLEGE ST
Mailing Address - Street 2:STE 3
Mailing Address - City:PULASKI
Mailing Address - State:TN
Mailing Address - Zip Code:38478
Mailing Address - Country:US
Mailing Address - Phone:931-424-8881
Mailing Address - Fax:931-424-5385
Practice Address - Street 1:1119 E COLLEGE ST
Practice Address - Street 2:STE 3
Practice Address - City:PULASKI
Practice Address - State:TN
Practice Address - Zip Code:38478
Practice Address - Country:US
Practice Address - Phone:931-424-8881
Practice Address - Fax:931-424-5385
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26439207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3088920Medicaid
C71979Medicare UPIN
3088920Medicare ID - Type Unspecified