Provider Demographics
NPI:1396735882
Name:BURGESS, KRAIG M (DO)
Entity type:Individual
Prefix:
First Name:KRAIG
Middle Name:M
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DO
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 80217
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85060-0217
Mailing Address - Country:US
Mailing Address - Phone:602-385-2115
Mailing Address - Fax:480-418-3323
Practice Address - Street 1:18555 N 79TH AVE STE E101
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8392
Practice Address - Country:US
Practice Address - Phone:602-648-5444
Practice Address - Fax:602-772-3801
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4169207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ954348Medicaid
AZZ151459Medicare PIN
5437400001Medicare NSC
AZI27956Medicare UPIN