Provider Demographics
NPI:1659396224
Name:BURNSIDE, NANCY J (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:J
Last Name:BURNSIDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SCHOOL ST
Mailing Address - Street 2:SUITE 216
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-5334
Mailing Address - Country:US
Mailing Address - Phone:401-728-6990
Mailing Address - Fax:401-729-0930
Practice Address - Street 1:333 SCHOOL ST
Practice Address - Street 2:SUITE 216
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-5334
Practice Address - Country:US
Practice Address - Phone:401-728-6990
Practice Address - Fax:401-729-0930
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RIMD09795207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H05526Medicare UPIN