Provider Demographics
NPI:1689705055
Name:JESSE M WESBERRY MD PSC
Entity Type:Organization
Organization Name:JESSE M WESBERRY MD PSC
Other - Org Name:WESBERRY SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT/OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WESBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-362-3100
Mailing Address - Street 1:2900 S PERKINS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3237
Mailing Address - Country:US
Mailing Address - Phone:901-362-3100
Mailing Address - Fax:901-362-3372
Practice Address - Street 1:2900 S PERKINS RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3237
Practice Address - Country:US
Practice Address - Phone:901-362-3100
Practice Address - Fax:901-362-3372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44-1011261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0005869351OtherAETNA PROVIDER NUMBER
TN44-1011OtherSTATE ASTC LICENSE
TN490000574OtherRAILROAD MEDICARE
TN81353OtherBCBS PROVIDER NUMBER
TN3287121Medicare PIN