Provider Demographics
NPI:1497286629
Name:BURGHGRAEF, KYLE BRIAN
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:BRIAN
Last Name:BURGHGRAEF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 CHILDRENS DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2664
Mailing Address - Country:US
Mailing Address - Phone:614-722-2000
Mailing Address - Fax:
Practice Address - Street 1:5030 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:SOUTH BLOOMFIELD
Practice Address - State:OH
Practice Address - Zip Code:43103-1018
Practice Address - Country:US
Practice Address - Phone:740-983-0015
Practice Address - Fax:740-983-4763
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351390892080P0204X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396565Medicaid