Provider Demographics
NPI:1942280573
Name:BURNSIDE, ALLAN SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:SCOTT
Last Name:BURNSIDE
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 908
Mailing Address - Street 2:
Mailing Address - City:DOLORES
Mailing Address - State:CO
Mailing Address - Zip Code:81323-0908
Mailing Address - Country:US
Mailing Address - Phone:970-882-7221
Mailing Address - Fax:970-882-4243
Practice Address - Street 1:507 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOLORES
Practice Address - State:CO
Practice Address - Zip Code:81323
Practice Address - Country:US
Practice Address - Phone:970-882-7221
Practice Address - Fax:970-882-7221
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO32885207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO12635871OtherRURAL HEALTH CLINIC
CO5502AMGR004393OtherANTHEM
CO01328855Medicaid
CO080053393OtherRAILROAD MEDICARE
COC91708Medicare ID - Type UnspecifiedMEDICARE B-NORIDIAN
COE45463Medicare UPIN
CO01328855Medicaid