Provider Demographics
NPI:1720557150
Name:BURGUNDY PRIME INC
Entity Type:Organization
Organization Name:BURGUNDY PRIME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ABID
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-777-8084
Mailing Address - Street 1:430 WAYMONT CT STE 100
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-6745
Mailing Address - Country:US
Mailing Address - Phone:407-878-0022
Mailing Address - Fax:407-369-4267
Practice Address - Street 1:430 WAYMONT CT STE 100
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-6745
Practice Address - Country:US
Practice Address - Phone:407-878-0022
Practice Address - Fax:407-369-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084B0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyObesity MedicineGroup - Multi-Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty