Provider Demographics
NPI:1407823339
Name:BURGOYNE, PAUL XAVIER (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:XAVIER
Last Name:BURGOYNE
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 1:19901 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1069
Mailing Address - Country:US
Mailing Address - Phone:586-777-1277
Mailing Address - Fax:586-777-0106
Practice Address - Street 1:19901 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1069
Practice Address - Country:US
Practice Address - Phone:586-777-1277
Practice Address - Fax:586-777-0106
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301065935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700E031610OtherBCBS GROUP NUMBER
MI0P27380OtherMEDICARE GROUP LEGACY #
MI4573174Medicaid
MIP27380003Medicare PIN
MI700E031610OtherBCBS GROUP NUMBER
G74868Medicare UPIN
MI0P27380Medicare PIN
MIMI3971Medicare PIN