Provider Demographics
NPI:1043201361
Name:BURGESS, JASON SHADE (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:SHADE
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 33369
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28233-3369
Mailing Address - Country:US
Mailing Address - Phone:704-364-8100
Mailing Address - Fax:704-365-2073
Practice Address - Street 1:2001 VAIL AVENUE
Practice Address - Street 2:STE 320
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1107
Practice Address - Country:US
Practice Address - Phone:704-333-0741
Practice Address - Fax:704-333-3356
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200093208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000396DOtherMEDICARE PIN FACULTY
NC891305AMedicaid
2000396OtherMEDICARE
2000396Medicare PIN
2000396DOtherMEDICARE PIN FACULTY