Provider Demographics
NPI:1497744684
Name:BURNSIDE, LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:BURNSIDE
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 1:325 9TH AVE
Mailing Address - Street 2:BOX 359860
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-2420
Mailing Address - Country:US
Mailing Address - Phone:206-897-2110
Mailing Address - Fax:206-744-9976
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:BOX 359860
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-897-2110
Practice Address - Fax:206-744-9976
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033954207R00000X
WAMD33954207RG0300X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00307116OtherRAILROAD MC # VM
WA8205866Medicaid
WAUS5478718OtherAETNA SPECIALIST PIN # VM
WA0039581OtherLABOR AND INDUSTRIES # VM
WA9385BUOtherBLUE SHIELD # VM
WA8859661Medicare PIN
WA8205866Medicaid
WA9385BUOtherBLUE SHIELD # VM
WA0039581OtherLABOR AND INDUSTRIES # VM