Provider Demographics
NPI:1225004401
Name:BURNSIDE, STEPHEN SPENCER (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:SPENCER
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615
Mailing Address - Country:US
Mailing Address - Phone:907-486-6065
Mailing Address - Fax:907-486-2248
Practice Address - Street 1:1818 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615
Practice Address - Country:US
Practice Address - Phone:907-486-6065
Practice Address - Fax:907-486-2248
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAA2876207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK920088665OtherEMPLOYEE ID
AKGR0173Medicaid
AKMD 03803Medicaid
AKMD 03803Medicaid
AK920088665OtherEMPLOYEE ID
011WCHHTBMedicare ID - Type Unspecified