Provider Demographics
NPI:1073956421
Name:STANLEY, BURGUNDY SHAREE (MD)
Entity Type:Individual
Prefix:
First Name:BURGUNDY
Middle Name:SHAREE
Last Name:STANLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 N SHADELAND AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4959
Practice Address - Country:US
Practice Address - Phone:317-963-2514
Practice Address - Fax:317-962-4343
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01076914A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201364410Medicaid
INP01718887Medicare PIN
IN264430441Medicare PIN
IN200640033Medicare PIN