Provider Demographics
NPI:1518062199
Name:BURT, STEPHEN MARCEL (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:MARCEL
Last Name:BURT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 425
Mailing Address - Street 2:1111 HIGHWAY 441 NORTH
Mailing Address - City:PEARSON
Mailing Address - State:GA
Mailing Address - Zip Code:31642
Mailing Address - Country:US
Mailing Address - Phone:912-422-7073
Mailing Address - Fax:912-422-7019
Practice Address - Street 1:1111 HIGHWAY 441 NORTH
Practice Address - Street 2:
Practice Address - City:PEARSON
Practice Address - State:GA
Practice Address - Zip Code:31642
Practice Address - Country:US
Practice Address - Phone:912-422-7073
Practice Address - Fax:912-422-7019
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025727208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA010062912OtherRAILROAD MEDICARE
GA00272995EMedicaid
GA010062912OtherRAILROAD MEDICARE
F95770Medicare UPIN
GAF95770Medicare UPIN