Basic Information
| Provider Information | |||||||||
| NPI: | 1831256957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | JERALD | ||||||||
| MiddleName: | MILLER | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 MEDICAL LOOP | ||||||||
| Address2: | SUITE #3 | ||||||||
| City: | WHITLEY CITY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426534382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063765391 | ||||||||
| FaxNumber: | 6063763326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 04/22/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 17906 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64179062 | 05 | KY | MEDICAID |