Provider Demographics
NPI:1134487473
Name:BURG, MARISSA JANEL (MD)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:JANEL
Last Name:BURG
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 1:25 HOPKINS RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-4641
Mailing Address - Country:US
Mailing Address - Phone:716-632-8050
Mailing Address - Fax:716-632-2297
Practice Address - Street 1:25 HOPKINS RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-4641
Practice Address - Country:US
Practice Address - Phone:716-632-8050
Practice Address - Fax:716-632-2297
Is Sole Proprietor?:No
Enumeration Date:2012-04-24
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY278116-1208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04239176Medicaid