Provider Demographics
NPI:1538369343
Name:SPIVEY, JERRY ALLEN JR (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:ALLEN
Last Name:SPIVEY
Suffix:JR
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:PO BOX 80883
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30608-0883
Mailing Address - Country:US
Mailing Address - Phone:706-549-8114
Mailing Address - Fax:706-549-7558
Practice Address - Street 1:1030 FOUNDERS ROW
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642
Practice Address - Country:US
Practice Address - Phone:706-433-0723
Practice Address - Fax:706-549-7558
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065063207L00000X, 207LP2900X
GA65063208VP0000X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003115310CMedicaid
GA003115310BMedicaid
GA003115310EMedicaid
GA003115310EMedicaid
GA202I050024Medicare PIN