Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | MD-059218-L | PA |
NPI | 1689696486 |
---|---|
Provider Name | Dr. Edward C Burnetta |
First Address | Bryn Mawr, PA 19010-2079 |
Second Address | Bryn Mawr, PA 19010-2079 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0073081140001 | (05) | PA |
G56140 | (02) | PA |