Provider Demographics
NPI:1598035917
Name:P. ROMAN BURK DPM, PC
Entity Type:Organization
Organization Name:P. ROMAN BURK DPM, PC
Other - Org Name:FOOT & ANKLE MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-459-0891
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:1818 S 10TH AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4803
Practice Address - Country:US
Practice Address - Phone:208-459-0891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P. ROMAN BURK DPM, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-02
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site