Provider Demographics
NPI:1124045752
Name:BURNSIDE, DAVID WAYNE (MD, MBA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYNE
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMIT DRIVE
Mailing Address - Street 2:LOCKBOX 1876
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1876
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:
Practice Address - Street 1:1 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6722
Practice Address - Country:US
Practice Address - Phone:618-463-7311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-090895207P00000X
KY2666207P00000X
MO107364207P00000X
OH25.067203207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208063727Medicaid
IL036090895Medicaid
IL036090895-3Medicaid
ILL75316Medicare PIN
IL036090895Medicaid
MO937094740Medicare PIN
MO000013209Medicare PIN
MO937094748Medicare PIN
E39227Medicare UPIN