1063646610 NPI number — MR. COREY A BURGESS

Table of content: MR. COREY A BURGESS (NPI 1063646610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063646610 NPI number — MR. COREY A BURGESS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
COREY
Provider Middle Name:
A
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1063646610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1775 BRIGATINE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMTER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29154-7377
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-406-4886
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3236 HWY 15 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMTER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29150-9657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-506-2005
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2009

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: 171W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 341600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1063646610 . This is a "NPPES" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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