Provider Demographics
NPI:1811229388
Name:BURGESS, RICKY G
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:G
Last Name:BURGESS
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 1:10 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SENECA FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:13148-1214
Mailing Address - Country:US
Mailing Address - Phone:303-503-0868
Mailing Address - Fax:
Practice Address - Street 1:2360 STATE ROUTE 89
Practice Address - Street 2:
Practice Address - City:SENECA FALLS
Practice Address - State:NY
Practice Address - Zip Code:13148-9425
Practice Address - Country:US
Practice Address - Phone:800-234-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program