Provider Demographics
NPI:1679678122
Name:BURNELL, RICHARD A (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:BURNELL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 SPARKLEBERRY LANE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:SC
Mailing Address - Zip Code:29020-9197
Mailing Address - Country:US
Mailing Address - Phone:803-669-2709
Mailing Address - Fax:803-713-1310
Practice Address - Street 1:133 SPARKLEBERRY LN
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:SC
Practice Address - Zip Code:29020-9197
Practice Address - Country:US
Practice Address - Phone:803-669-2709
Practice Address - Fax:803-713-1310
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC547213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPD5473Medicaid
SC480031163OtherMEDICARE RAILROAD PIN
SCPD5473Medicaid
SC6072870001Medicare NSC
SC8591Medicare PIN