Healthcare Provider Details

I. General information

NPI: 1679779276
Provider Name (Legal Business Name): JESSE LEE PACE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 08/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 E UNIVERSITY DR
AUBURN AL
36832-5889
US

IV. Provider business mailing address

353 BOGLE ST SUITE C
SOMERSET KY
42503-2888
US

V. Phone/Fax

Practice location:
  • Phone: 334-826-2090
  • Fax: 334-821-3191
Mailing address:
  • Phone: 606-678-2220
  • Fax: 606-678-2219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number34.008380
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberDO.1014
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS12882
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number03290
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: