Provider Demographics
NPI:1235113408
Name:BURDGE, JEREMY J (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:J
Last Name:BURDGE
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 1:3732 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3449
Mailing Address - Country:US
Mailing Address - Phone:614-451-0411
Mailing Address - Fax:614-451-8037
Practice Address - Street 1:3732 OLENTANGY RIVER RD
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3449
Practice Address - Country:US
Practice Address - Phone:614-451-0411
Practice Address - Fax:614-451-8037
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-042744174400000X
OH35.042744208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0553753Medicaid
OH000000118889OtherANTHEM PROVIDER ID
OHA80856Medicare UPIN
OHBU0547684Medicare ID - Type UnspecifiedMEDICARE ID