Provider Demographics
NPI:1235498833
Name:JOSEPH BURNETTE, LLC
Entity Type:Organization
Organization Name:JOSEPH BURNETTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-330-6755
Mailing Address - Street 1:420 CHARTER BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4854
Mailing Address - Country:US
Mailing Address - Phone:478-330-6755
Mailing Address - Fax:478-330-6759
Practice Address - Street 1:420 CHARTER BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4854
Practice Address - Country:US
Practice Address - Phone:478-330-6755
Practice Address - Fax:478-330-6759
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033286208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00430669AMedicaid
GAE98391Medicare UPIN