Provider Demographics
NPI:1194179622
Name:BURGESS, ERNIE
Entity Type:Individual
Prefix:
First Name:ERNIE
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 CASS ST
Mailing Address - Street 2:SUITE 2A & 2D
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2589
Mailing Address - Country:US
Mailing Address - Phone:231-922-4810
Mailing Address - Fax:231-943-2590
Practice Address - Street 1:116 E 8TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2524
Practice Address - Country:US
Practice Address - Phone:231-922-4810
Practice Address - Fax:231-943-2590
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriver
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184087272Medicaid
MI1629431713Medicaid