Provider Demographics
NPI:1447224498
Name:BURT, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BURT
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 1:205 N TILLOTSON AVE
Mailing Address - Street 2:SUITE
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-3900
Mailing Address - Country:US
Mailing Address - Phone:765-289-2353
Mailing Address - Fax:
Practice Address - Street 1:205 N TILLOTSON AVE
Practice Address - Street 2:SUITE
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3900
Practice Address - Country:US
Practice Address - Phone:765-289-2353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2013-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028368208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200014320AMedicaid