Provider Demographics
NPI:1649274044
Name:BURDETTE, MICHELLE R (MD, RETIRED)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:BURDETTE
Suffix:
Gender:F
Credentials:MD, RETIRED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4605 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1311
Practice Address - Country:US
Practice Address - Phone:304-414-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16928207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1649274044Medicaid
WVB441OtherGROUP MEDICARE
WV3810024049OtherGROUP MEDICAID
WV0053794000Medicaid
WVF48114Medicare UPIN
WVWV6059B441Medicare PIN