Provider Demographics
NPI:1508052333
Name:BURGOYNE, CHADLER R (MD)
Entity Type:Individual
Prefix:
First Name:CHADLER
Middle Name:R
Last Name:BURGOYNE
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:SANSUM ORTHOPEDIC CLINIC
Mailing Address - Street 2:4151 FOOTHILL RD - BLDG A
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110
Mailing Address - Country:US
Mailing Address - Phone:805-681-7500
Mailing Address - Fax:
Practice Address - Street 1:SANSUM ORTHOPEDIC CLINIC
Practice Address - Street 2:4151 FOOTHILL RD - BLDG A
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93110
Practice Address - Country:US
Practice Address - Phone:805-681-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154654207X00000X
CAA99619207XX0005X
SC31285207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1326287434OtherMEDICAID DME NPI
SC312851Medicaid
SC57-0634057OtherGROUP TAX ID #
SC1701OtherGROUP MEDICARE
SC20076508OtherSELECT HEALTH DME
SC20081812OtherSELECT HEALTH FIRST CHOICE
SC1225006760OtherGROUP NPI #
SC20081812OtherSELECT HEALTH FIRST CHOICE