Provider Demographics
NPI:1164469193
Name:THOMAS-BURSE, JANELLA LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:JANELLA
Middle Name:LYNNE
Last Name:THOMAS-BURSE
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 1:105 CLEARBROOK PL SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8066
Mailing Address - Country:US
Mailing Address - Phone:404-349-8024
Mailing Address - Fax:
Practice Address - Street 1:1720 PHOENIX BLVD
Practice Address - Street 2:SUITE 700
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5594
Practice Address - Country:US
Practice Address - Phone:404-446-4792
Practice Address - Fax:404-446-4793
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043493207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA732174576AMedicaid
GA16BDVGPMedicare ID - Type Unspecified
GA732174576AMedicaid