Provider Demographics
NPI:1184330318
Name:BURRUS, ALBERT WILLIE JR
Entity type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:WILLIE
Last Name:BURRUS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ALBERT
Other - Middle Name:W
Other - Last Name:BURRUS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8610A W POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4138
Mailing Address - Country:US
Mailing Address - Phone:312-505-2519
Mailing Address - Fax:
Practice Address - Street 1:8610A W POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-4138
Practice Address - Country:US
Practice Address - Phone:312-505-2519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI9211920762Medicaid
WI92192762Medicaid