Provider Demographics
NPI:1437261039
Name:BURGESS, EVERETT CARL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EVERETT
Middle Name:CARL
Last Name:BURGESS
Suffix:JR
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 1:2937 IVANHOE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44224-3011
Mailing Address - Country:US
Mailing Address - Phone:330-923-4118
Mailing Address - Fax:
Practice Address - Street 1:75 ARCH ST STE 301
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44304-1429
Practice Address - Country:US
Practice Address - Phone:330-762-8875
Practice Address - Fax:330-762-2165
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35040675174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0343891Medicaid
OH0343891Medicaid
OHBU0438621Medicare ID - Type Unspecified