Provider Demographics
NPI:1295801520
Name:BURT, ROY G (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:G
Last Name:BURT
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-6585
Mailing Address - Fax:605-328-6512
Practice Address - Street 1:3015 3RD AVE SE
Practice Address - Street 2:STE 100
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-5418
Practice Address - Country:US
Practice Address - Phone:605-725-1700
Practice Address - Fax:605-725-1708
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1376174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD1376OtherDAKOTACARE
SD6600040Medicaid
SD1376OtherDAKOTACARE
SD6600040Medicaid