Provider Demographics
NPI:1891983037
Name:KELLY D. BURCHETT DO LLC
Entity Type:Organization
Organization Name:KELLY D. BURCHETT DO LLC
Other - Org Name:ADVANCED SURGICAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BURCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-665-3599
Mailing Address - Street 1:1605 SOUTH BALTIMORE
Mailing Address - Street 2:SUITE B
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501
Mailing Address - Country:US
Mailing Address - Phone:660-665-3599
Mailing Address - Fax:660-665-3599
Practice Address - Street 1:1605 SOUTH BALTIMORE
Practice Address - Street 2:SUITE B
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501
Practice Address - Country:US
Practice Address - Phone:660-665-3599
Practice Address - Fax:660-665-3570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010344207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000014669Medicare PIN