Provider Demographics
NPI:1336141704
Name:BURKE, JEFF PHILIP (PT)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:PHILIP
Last Name:BURKE
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 1:929 WEST ST
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9309
Mailing Address - Country:US
Mailing Address - Phone:231-675-6920
Mailing Address - Fax:
Practice Address - Street 1:4045 W ROYAL DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-8965
Practice Address - Country:US
Practice Address - Phone:231-935-0901
Practice Address - Fax:231-935-0308
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4491328Medicaid
MI4496647Medicaid
MI4491328Medicaid