Provider Demographics
NPI:1114912656
Name:BURRUS, ROGER GRADY (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:GRADY
Last Name:BURRUS
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 1:323 STEAM PLANT RD
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066-3025
Mailing Address - Country:US
Mailing Address - Phone:615-452-1060
Mailing Address - Fax:615-452-5474
Practice Address - Street 1:123 FAIRWAYS DR
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2610
Practice Address - Country:US
Practice Address - Phone:615-969-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-12
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20833174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3074639Medicaid
TN3074639Medicare ID - Type Unspecified
TNF59639Medicare UPIN