Provider Demographics
NPI:1013072974
Name:BURNSIDE, TOM MARTIN
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:MARTIN
Last Name:BURNSIDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 ANDERSON FERRY RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-5285
Mailing Address - Country:US
Mailing Address - Phone:513-922-6537
Mailing Address - Fax:
Practice Address - Street 1:417 ANDERSON FERRY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-5285
Practice Address - Country:US
Practice Address - Phone:513-922-6537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI1507101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH77798284Medicare UPIN