1912934134 NPI number — MRS. BRENDA K BURK

Table of content: MRS. BRENDA K BURK (NPI 1912934134)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912934134 NPI number — MRS. BRENDA K BURK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURK
Provider First Name:
BRENDA
Provider Middle Name:
K
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ROWLETT
Provider Other First Name:
BRENDA
Provider Other Middle Name:
K
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912934134
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 FADE AWAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65616
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-238-3698
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3660 SOUTH NATIONAL AVE
Provider Second Line Business Practice Location Address:
OXFORD HEALTHCARE
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65808-0939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-883-7552
Provider Business Practice Location Address Fax Number:
417-841-2854
Provider Enumeration Date:
06/26/2006

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: 225X00000X , with the licence number:  OTR 1605 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X , with the licence number: 1091 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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