1336435403 NPI number — HEALTHSURE MEDICAL CLINIC PLLC

Table of content: (NPI 1336435403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336435403 NPI number — HEALTHSURE MEDICAL CLINIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHSURE MEDICAL CLINIC PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336435403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2406 GREATSTONE POINT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40504-3274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-223-0006
Provider Business Mailing Address Fax Number:
859-224-0005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2406 GREATSTONE PT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40504-3274
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-223-0006
Provider Business Practice Location Address Fax Number:
859-224-0005
Provider Enumeration Date:
06/27/2011

Additional Information

Authorized Official

Authorized Official Last Name:
JESSA
Authorized Official First Name:
PEACE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
859-223-0006

Provider Taxonomy Codes

  • Taxonomy code: 2083X0100X , with the licence number:  02871 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000736990 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100185990 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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