1518194984 NPI number — MATTHEW BURRUSS M.D.

Table of content: MATTHEW BURRUSS M.D. (NPI 1518194984)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518194984 NPI number — MATTHEW BURRUSS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRUSS
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1518194984
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5012 S US HIGHWAY 75 STE 300
Provider Second Line Business Mailing Address:
ATTN BILLING
Provider Business Mailing Address City Name:
DENISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75020-4589
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-416-6490
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5012 S US HIGHWAY 75 STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENISON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75020-4611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-416-6490
Provider Business Practice Location Address Fax Number:
903-463-1201
Provider Enumeration Date:
06/12/2009

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: 208600000X , with the licence number:  2014-01688 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19CQ8 . This is a "BCBS NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1518194984 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".