Provider Demographics
NPI:1568629418
Name:KELLY BURGESS M.D.
Entity Type:Organization
Organization Name:KELLY BURGESS M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-863-5150
Mailing Address - Street 1:1140 LEXINGTON RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9330
Mailing Address - Country:US
Mailing Address - Phone:502-863-5150
Mailing Address - Fax:502-863-4487
Practice Address - Street 1:1140 LEXINGTON RD
Practice Address - Street 2:SUITE 200
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9330
Practice Address - Country:US
Practice Address - Phone:502-863-5150
Practice Address - Fax:502-863-4487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000368877OtherBCBS
KY64017783Medicaid
KYG63969OtherUPIN
KY64017783Medicaid