Provider Demographics
NPI:1609853324
Name:BURCH, MARY CATHERINE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CATHERINE
Last Name:BURCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIVERBEND DR SW
Mailing Address - Street 2:STE 100
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6065
Mailing Address - Country:US
Mailing Address - Phone:706-291-0884
Mailing Address - Fax:706-235-0405
Practice Address - Street 1:15 RIVERBEND DR SW
Practice Address - Street 2:STE 100
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6065
Practice Address - Country:US
Practice Address - Phone:706-291-0884
Practice Address - Fax:706-235-0405
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA084921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0092323813Medicaid
P56946Medicare UPIN
50BBFXMMedicare ID - Type Unspecified