Provider Demographics
NPI:1336435403
Name:HEALTHSURE MEDICAL CLINIC PLLC
Entity Type:Organization
Organization Name:HEALTHSURE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PEACE
Authorized Official - Middle Name:N
Authorized Official - Last Name:JESSA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:859-223-0006
Mailing Address - Street 1:2406 GREATSTONE POINT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3274
Mailing Address - Country:US
Mailing Address - Phone:859-223-0006
Mailing Address - Fax:859-224-0005
Practice Address - Street 1:2406 GREATSTONE PT
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-223-0006
Practice Address - Fax:859-224-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY028712083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000736990OtherANTHEM
KY7100185990Medicaid
KY7100185990Medicaid