Provider Demographics
NPI:1093745580
Name:BURGOYNE, RICHARD ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ANDREW
Last Name:BURGOYNE
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 547
Mailing Address - Street 2:CENTRAL VERMONT MEDICAL CENTER - FINANCE DEPT
Mailing Address - City:BARRE
Mailing Address - State:VT
Mailing Address - Zip Code:05641-0547
Mailing Address - Country:US
Mailing Address - Phone:802-244-7874
Mailing Address - Fax:802-244-4106
Practice Address - Street 1:130 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:VT
Practice Address - Zip Code:05676-1519
Practice Address - Country:US
Practice Address - Phone:802-244-7874
Practice Address - Fax:802-244-4106
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0042816207Q00000X
VT0420011847207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD751121300Medicaid
VT1016787Medicaid
VT001299701Medicare PIN
MD751121300Medicaid
MD887L273EMedicare ID - Type Unspecified
MD887L273EMedicare ID - Type Unspecified