Provider Demographics
NPI:1457307381
Name:THE BURGOYNE INSTITUTE, LLC
Entity Type:Organization
Organization Name:THE BURGOYNE INSTITUTE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:BURGOYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-464-4431
Mailing Address - Street 1:PO BOX 94448
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85070-4448
Mailing Address - Country:US
Mailing Address - Phone:480-862-4427
Mailing Address - Fax:480-464-2338
Practice Address - Street 1:4055 W CHANDLER BLVD
Practice Address - Street 2:STE 5
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-3732
Practice Address - Country:US
Practice Address - Phone:480-464-4431
Practice Address - Fax:480-464-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z109835Medicare PIN