Provider Demographics
NPI:1477544377
Name:BURGESS, THERESA CATHERINE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:CATHERINE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 LEINBACH DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-1619
Mailing Address - Country:US
Mailing Address - Phone:336-416-6796
Mailing Address - Fax:
Practice Address - Street 1:725 HIGHLAND AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4180
Practice Address - Country:US
Practice Address - Phone:336-607-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC289502084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891114PMedicaid
NCC81981Medicare UPIN
NC891114PMedicaid