Provider Demographics
NPI:1689722894
Name:BURRESS, ROGER DALE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
Last Name:BURRESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E DIVISION RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6938
Mailing Address - Country:US
Mailing Address - Phone:865-483-8899
Mailing Address - Fax:865-483-8829
Practice Address - Street 1:150 E DIVISION RD
Practice Address - Street 2:SUITE 4
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6938
Practice Address - Country:US
Practice Address - Phone:865-483-8899
Practice Address - Fax:865-483-8829
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0165632084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3037870Medicare ID - Type Unspecified
TNB00105Medicare UPIN