1285903146 NPI number — DR. BRIAN JOHN BURGESS DPM

Table of content: DR. BRIAN JOHN BURGESS DPM (NPI 1285903146)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285903146 NPI number — DR. BRIAN JOHN BURGESS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
BRIAN
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1285903146
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 W OGDEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HINSDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60521-3186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-323-6116
Provider Business Mailing Address Fax Number:
630-323-5309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2940 ROLLINGRIDGE RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
NAPERVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60564-4231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-579-6500
Provider Business Practice Location Address Fax Number:
630-579-5860
Provider Enumeration Date:
12/22/2011

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: 213ES0103X , with the licence number:  135-000678 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 016005467 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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