Provider Demographics
NPI:1093310104
Name:BURGAN III, WALTER L
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:L
Last Name:BURGAN III
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 1:4024 MOUNT EATON RD
Mailing Address - Street 2:
Mailing Address - City:ORRVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44667-9024
Mailing Address - Country:US
Mailing Address - Phone:330-603-8300
Mailing Address - Fax:
Practice Address - Street 1:4024 MOUNT EATON RD
Practice Address - Street 2:
Practice Address - City:ORRVILLE
Practice Address - State:OH
Practice Address - Zip Code:44667-9024
Practice Address - Country:US
Practice Address - Phone:330-603-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle