Provider Demographics
NPI:1417048596
Name:BURCHUK, DAVID GLENN (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:GLENN
Last Name:BURCHUK
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 1:29 GARRISON LN
Mailing Address - Street 2:
Mailing Address - City:MADBURY
Mailing Address - State:NH
Mailing Address - Zip Code:03823-7605
Mailing Address - Country:US
Mailing Address - Phone:603-749-6496
Mailing Address - Fax:603-422-8849
Practice Address - Street 1:1 CATE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7108
Practice Address - Country:US
Practice Address - Phone:603-431-0277
Practice Address - Fax:603-422-8849
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE8639Medicare PIN