Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207X00000X | Orthopaedic Surgeon | R5609 | MO |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | R5609 | MO |
NPI | 1053419291 |
---|---|
Provider Name | Bruce W. Burleigh |
First Address | Joplin, MO 64803-3810 |
Second Address | Joplin, MO 64804-3932 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 16/10/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7052 | ANTHEM (01) | MO |
A12595 | (02) | |
P00352970 | RR MEDICARE (01) |