Provider Demographics
NPI:1023067816
Name:BURRELL, MICHAEL J (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:BURRELL
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 1:2525 W UNIVERSITY AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-3409
Mailing Address - Country:US
Mailing Address - Phone:765-289-9415
Mailing Address - Fax:765-289-3883
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3409
Practice Address - Country:US
Practice Address - Phone:765-289-6381
Practice Address - Fax:765-289-3883
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033256A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200112850Medicaid
IN000000711219OtherANTHEM
INP00968535OtherRR MEDICARE
IN000000711219OtherANTHEM
INP00968535OtherRR MEDICARE
IN200112850Medicaid
IN203410DMedicare PIN