Provider Demographics
NPI:1205858438
Name:BURGESS, SCOTT CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CHRISTOPHER
Last Name:BURGESS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1842
Mailing Address - Country:US
Mailing Address - Phone:304-388-7782
Mailing Address - Fax:304-388-7788
Practice Address - Street 1:130 GOFF MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:CROSS LANES
Practice Address - State:WV
Practice Address - Zip Code:25313-1419
Practice Address - Country:US
Practice Address - Phone:304-388-7055
Practice Address - Fax:304-388-7508
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810006515Medicaid
WV3810006515Medicaid