1467533646 NPI number — DR. RICHARD G. BURSUA O.D.

Table of content: DR. RICHARD G. BURSUA O.D. (NPI 1467533646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467533646 NPI number — DR. RICHARD G. BURSUA O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURSUA
Provider First Name:
RICHARD
Provider Middle Name:
G.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1467533646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/09/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1689
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARION
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62959-7889
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-997-6438
Provider Business Mailing Address Fax Number:
618-997-6430

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1306 N . RUSSELL ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-997-6438
Provider Business Practice Location Address Fax Number:
618-997-6430
Provider Enumeration Date:
10/17/2006

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: 152W00000X , with the licence number:  046006213 , 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: 046006213 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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