Provider Demographics
NPI:1568434454
Name:BURGHARDT, BETH MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:MICHELLE
Last Name:BURGHARDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 4L
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-452-2124
Mailing Address - Fax:315-452-2128
Practice Address - Street 1:5100 W TAFT RD
Practice Address - Street 2:SUITE 4L
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13088-3807
Practice Address - Country:US
Practice Address - Phone:315-452-2124
Practice Address - Fax:315-452-2128
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY185289207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY61719913OtherNYS PIN
NY01413107Medicaid
NY01413107Medicaid