1578930129 NPI number — CHRISTOPHER M BURDIS PT, DPT, CSCS

Table of content: CHRISTOPHER M BURDIS PT, DPT, CSCS (NPI 1578930129)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578930129 NPI number — CHRISTOPHER M BURDIS PT, DPT, CSCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURDIS
Provider First Name:
CHRISTOPHER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT, CSCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578930129
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18000 COVE ST
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
SPRING LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49456-1299
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-847-1280
Provider Business Mailing Address Fax Number:
616-847-1290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
SUITE 130A
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-994-8136
Provider Business Practice Location Address Fax Number:
616-994-8162
Provider Enumeration Date:
08/31/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501017340 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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