Provider Demographics
NPI:1972565026
Name:BURGESON, MARY (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:BURGESON
Suffix:
Gender:F
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 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-5255
Mailing Address - Fax:812-996-8497
Practice Address - Street 1:407 E 22ND ST
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-8964
Practice Address - Country:US
Practice Address - Phone:812-683-3612
Practice Address - Fax:812-683-2819
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325260Medicaid
IN210520BMedicare ID - Type Unspecified
IND95445Medicare UPIN
IN254260AMedicare PIN