Provider Demographics
NPI:1457350332
Name:BURTIS CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:BURTIS CHIROPRACTIC CENTER PA
Other - Org Name:BURTIS CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OF CORP, CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:P
Authorized Official - Last Name:BURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:507-235-5551
Mailing Address - Street 1:112 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4058
Mailing Address - Country:US
Mailing Address - Phone:507-235-5557
Mailing Address - Fax:507-238-4429
Practice Address - Street 1:112 N STATE ST
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-4058
Practice Address - Country:US
Practice Address - Phone:507-235-5557
Practice Address - Fax:507-238-4429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN59662FAOtherINSURANCE ID #
MN3D578BUOtherBLUE CROSS BLUE SHIELD
MN551328600Medicaid
MN359000585Medicare ID - Type UnspecifiedMEDICARE ID #
MN551328600Medicaid