Provider Demographics
NPI:1851396642
Name:BURNS, MICHAEL R (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:BURNS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 LANDMARK AVE
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-0550
Mailing Address - Country:US
Mailing Address - Phone:812-355-3405
Mailing Address - Fax:812-355-6538
Practice Address - Street 1:550 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-3239
Practice Address - Country:US
Practice Address - Phone:812-355-3405
Practice Address - Fax:812-355-6538
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001924A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200515100Medicaid
IN200515100Medicaid
IN200515100Medicaid