Provider Demographics
NPI:1972136919
Name:BURGEONING HEALTH PROVIDERS
Entity Type:Organization
Organization Name:BURGEONING HEALTH PROVIDERS
Other - Org Name:BURGEONING HEALTH PROVIDERS, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MALINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-BC
Authorized Official - Phone:317-659-5905
Mailing Address - Street 1:2345 N ALABAMA ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-4320
Mailing Address - Country:US
Mailing Address - Phone:317-659-5905
Mailing Address - Fax:
Practice Address - Street 1:646 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46204-1607
Practice Address - Country:US
Practice Address - Phone:317-659-5095
Practice Address - Fax:317-350-0043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-18
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021924Medicaid