Provider Demographics
NPI:1487110177
Name:JEROME, SAM (DPT, PT)
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:JEROME
Suffix:
Gender:M
Credentials:DPT, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:COVENTRY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44203-3855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1033 E TURKEYFOOT LAKE RD STE 201
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44312-7203
Practice Address - Country:US
Practice Address - Phone:330-896-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2019-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPT017897208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation