Provider Demographics
NPI:1861688046
Name:MARK L BURTMAN
Entity Type:Organization
Organization Name:MARK L BURTMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:BURTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-329-9191
Mailing Address - Street 1:505 WILLOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2016
Mailing Address - Country:US
Mailing Address - Phone:662-329-9191
Mailing Address - Fax:662-329-9194
Practice Address - Street 1:505 WILLOWBROOK RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2016
Practice Address - Country:US
Practice Address - Phone:662-329-9191
Practice Address - Fax:662-329-9194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty