Provider Demographics
NPI:1336279116
Name:RANDALL BURT MD PA
Entity Type:Organization
Organization Name:RANDALL BURT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-981-7777
Mailing Address - Street 1:6124 W PARKER RD
Mailing Address - Street 2:STE 134
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-8122
Mailing Address - Country:US
Mailing Address - Phone:972-981-7777
Mailing Address - Fax:972-981-7750
Practice Address - Street 1:6124 W PARKER RD
Practice Address - Street 2:STE 134
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-8122
Practice Address - Country:US
Practice Address - Phone:972-981-7777
Practice Address - Fax:972-981-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3933174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH-62091Medicare UPIN
TX00682TMedicare PIN