Provider Demographics
NPI:1184667909
Name:BURNHAM, ASHLEY L (MD)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:L
Last Name:BURNHAM
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:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-7930
Mailing Address - Fax:479-968-4331
Practice Address - Street 1:3301 W MAIN PL
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2334
Practice Address - Country:US
Practice Address - Phone:479-968-7930
Practice Address - Fax:479-968-1673
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE15202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142806001Medicaid
AR5L804OtherBCBS PROVIDER NUMBER
AR5L804Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
AR142806001Medicaid