Provider Demographics
NPI:1649563347
Name:P. ROMAN BURK DPM PC
Entity Type:Organization
Organization Name:P. ROMAN BURK DPM PC
Other - Org Name:ROCKY MOUNTAINT FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:P ROMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-855-5955
Mailing Address - Street 1:1818 S 10TH AVE
Mailing Address - Street 2:#250
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4803
Mailing Address - Country:US
Mailing Address - Phone:208-855-5955
Mailing Address - Fax:208-459-8628
Practice Address - Street 1:2667 E GALA CT STE 130
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2788
Practice Address - Country:US
Practice Address - Phone:208-795-5090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-27
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP197213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808001900Medicaid
ID000000000154263OtherREGENCE
IDP9383OtherBLUE CROSS
ID000000000154263OtherREGENCE
ID101122Medicare PIN