1578558805 NPI number — DR. NORRIS KENT BURTON M.D.

Table of content: GUIALIX DOUYON (NPI 1679214878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578558805 NPI number — DR. NORRIS KENT BURTON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURTON
Provider First Name:
NORRIS
Provider Middle Name:
KENT
Provider Name Prefix Text:
DR.
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:
1578558805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
907 18TH ST E STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-3643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-353-4325
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
907 18TH ST E
Provider Second Line Business Practice Location Address:
SUITE 140
Provider Business Practice Location Address City Name:
TIFTON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31794-3643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
229-353-4325
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/13/2005

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: 207Q00000X , with the licence number:  031888 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 52576054 002 . This is a "BCBS OF GA PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 000398593E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 52576054 002 . This is a "GA DEPT. OF COMMUNITY HEA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 010031078 . This is a "RAILROAD MEDICARE PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 900158275 . This is a "TRICARE PIN" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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