Basic Information
| Provider Information | |||||||||
| NPI: | 1235194994 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | JERALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 ALICE PECK DAY DR | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | NH | ||||||||
| PostalCode: | 037662694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034483121 | ||||||||
| FaxNumber: | 6034487462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2006 | ||||||||
| LastUpdateDate: | 04/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12683 | NH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 12683 | NH | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 020473740 | 01 | NH | TRICARE | OTHER | 020473740 | 01 | NH | GREAT WEST HEALTHCARE | OTHER | 020473740 | 01 | NH | HUMANA CHOICE CARE NETWOR | OTHER | 1367002 | 01 | NH | CIGNA | OTHER | 3968512 | 01 | NH | AETNA | OTHER | 00000834 | 05 | NH | MEDICAID | 0101506YOVT02 | 01 | NH | ANTHEM | OTHER | 020473740 | 01 | NH | UNITED HEALTHCARE | OTHER | 020473740 | 01 | NH | PRIVATE HEALTHCARE SYSTEM | OTHER | D03208 | 01 | NH | HARVARD PILGRIM | OTHER | 020473740 | 01 | NH | HEALTHCARE VALUE MGMT | OTHER |