Provider Demographics
NPI:1710571716
Name:BURNSIDE, MICHAEL S
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:S
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 WILD CHERRY RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-2509
Mailing Address - Country:US
Mailing Address - Phone:304-282-6863
Mailing Address - Fax:
Practice Address - Street 1:127 WILD CHERRY RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-2509
Practice Address - Country:US
Practice Address - Phone:304-282-6863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker