Provider Demographics
NPI:1013190602
Name:JERRY W CONNERS MD PSC
Entity Type:Organization
Organization Name:JERRY W CONNERS MD PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CONNERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:859-781-2700
Mailing Address - Street 1:40 NORTH GRAND AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FT THOMAS
Mailing Address - State:KY
Mailing Address - Zip Code:41075
Mailing Address - Country:US
Mailing Address - Phone:859-781-2700
Mailing Address - Fax:859-781-2712
Practice Address - Street 1:40 NORTH GRAND AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:FT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075
Practice Address - Country:US
Practice Address - Phone:859-781-2700
Practice Address - Fax:859-781-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15481207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64154818Medicaid
KY64154818Medicaid
KY7114Medicare PIN