1134446008 NPI number — MRS. DEE ANN BURGESS PTA, WCC

Table of content: MRS. DEE ANN BURGESS PTA, WCC (NPI 1134446008)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134446008 NPI number — MRS. DEE ANN BURGESS PTA, WCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
DEE
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PTA, WCC
Provider Gender Code:
F

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:
1134446008
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3801 OLD BRUCEVILLE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VINCENNES
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47591-3889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-886-4677
Provider Business Mailing Address Fax Number:
812-886-4678

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7465 MADISON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIANAPOLIS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46227-6564
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-788-3000
Provider Business Practice Location Address Fax Number:
317-788-3005
Provider Enumeration Date:
04/30/2010

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: 225200000X , with the licence number:  06002021A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 06002021A . This is a "PROFESSIONAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 6150719 . This is a "WOUND CARE CERTIFIED" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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