Provider Demographics
NPI:1871934133
Name:JESSEN SURGICAL, INC
Entity type:Organization
Organization Name:JESSEN SURGICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LAFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-781-1588
Mailing Address - Street 1:1326 ANDREA ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3334
Mailing Address - Country:US
Mailing Address - Phone:270-781-1588
Mailing Address - Fax:270-781-1598
Practice Address - Street 1:1326 ANDREA ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3334
Practice Address - Country:US
Practice Address - Phone:270-781-1588
Practice Address - Fax:270-781-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-15
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64293798Medicaid
KY64293798Medicaid