Provider Demographics
NPI:1831256957
Name:BURGESS, JERALD MILLER (MD)
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:MILLER
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:19 MEDICAL LOOP
Practice Address - Street 2:SUITE #3
Practice Address - City:WHITLEY CITY
Practice Address - State:KY
Practice Address - Zip Code:42653-4382
Practice Address - Country:US
Practice Address - Phone:606-376-5391
Practice Address - Fax:606-376-3326
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64179062Medicaid
C67515Medicare UPIN
KY64179062Medicaid