Provider Demographics
NPI:1851392492
Name:BURKE, STEPHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:BURKE
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:STE 3000
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-990-2400
Practice Address - Fax:423-990-2407
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD39699207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010210623Medicaid
TN3833880Medicaid
0281780001Medicare PIN
H40070Medicare UPIN
VA010210623Medicaid
TNP00246850Medicare PIN
TN3720181Medicare PIN
TN103I086169Medicare UPIN
TN3833880Medicare PIN
0281780003Medicare PIN
TN3833880Medicaid