Provider Demographics
NPI:1972897684
Name:BURKE, LOLA J (MD)
Entity Type:Individual
Prefix:
First Name:LOLA
Middle Name:J
Last Name:BURKE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2500 FOUNDATION WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401-9000
Mailing Address - Country:US
Mailing Address - Phone:304-285-7101
Mailing Address - Fax:304-285-7125
Practice Address - Street 1:1189 TIBWIN RD
Practice Address - Street 2:
Practice Address - City:MC CLELLANVILLE
Practice Address - State:SC
Practice Address - Zip Code:29458-9405
Practice Address - Country:US
Practice Address - Phone:843-887-3274
Practice Address - Fax:843-887-3817
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2022-07-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC39113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3810027539Medicaid
WVWV4396B987Medicare PIN