Provider Demographics
NPI:1639328578
Name:KELLY G BURKENSTOCK MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KELLY G BURKENSTOCK MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BURKENSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-727-7676
Mailing Address - Street 1:2040 N CAUSEWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-3116
Mailing Address - Country:US
Mailing Address - Phone:985-727-7676
Mailing Address - Fax:985-727-3476
Practice Address - Street 1:2040 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-3116
Practice Address - Country:US
Practice Address - Phone:985-727-7676
Practice Address - Fax:985-727-3476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.023319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1496278Medicaid
LAH02313Medicare UPIN
LA5E790Medicare PIN
LA5DH95Medicare PIN