Provider Demographics
NPI:1063646610
Name:BURGESS, COREY A
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 BRIGATINE DR
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29154-7377
Mailing Address - Country:US
Mailing Address - Phone:803-406-4886
Mailing Address - Fax:
Practice Address - Street 1:3236 HWY 15 S
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-9657
Practice Address - Country:US
Practice Address - Phone:803-506-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
No171W00000XOther Service ProvidersContractor
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1063646610OtherNPPES