Provider Demographics
NPI:1568766350
Name:SCOTT BURGE OD PC
Entity Type:Organization
Organization Name:SCOTT BURGE OD PC
Other - Org Name:DR. SCOTT BURGE, O.D., P.C.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BURGE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:703-821-1616
Mailing Address - Street 1:1471 CHAIN BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-5722
Mailing Address - Country:US
Mailing Address - Phone:703-821-1616
Mailing Address - Fax:
Practice Address - Street 1:1471 CHAIN BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-5722
Practice Address - Country:US
Practice Address - Phone:703-821-1616
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-07
Last Update Date:2011-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0601000890152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA422196Medicare UPIN