Provider Demographics
NPI:1538322854
Name:BURKE, BRIANT E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIANT
Middle Name:E
Last Name:BURKE
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 1:967 E PARKCENTER BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6721
Mailing Address - Country:US
Mailing Address - Phone:208-353-0158
Mailing Address - Fax:
Practice Address - Street 1:8100 W EMERALD ST STE 180
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9069
Practice Address - Country:US
Practice Address - Phone:208-377-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-6006207QA0401X
IDM6006207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDE57661Medicare UPIN