Provider Demographics
NPI:1588037154
Name:BURROUGHS, MARTY G SR
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:G
Last Name:BURROUGHS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15275 TEXAS RD
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-3232
Mailing Address - Country:US
Mailing Address - Phone:573-774-8364
Mailing Address - Fax:
Practice Address - Street 1:15275 TEXAS RD
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3232
Practice Address - Country:US
Practice Address - Phone:573-774-8364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-04
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOS135329002344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO$$$$$$$$$Medicaid