Provider Demographics
NPI:1578684437
Name:BURGESS, BRADFORD WAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:WAYNE
Last Name:BURGESS
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 1:210 VIRGINIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-2804
Mailing Address - Country:US
Mailing Address - Phone:706-206-8068
Mailing Address - Fax:
Practice Address - Street 1:27351 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3487
Practice Address - Country:US
Practice Address - Phone:248-967-7795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017098207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine