Provider Demographics
NPI:1649340530
Name:BURGESS, RICHARD ELY (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ELY
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 SILVER CROSS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-9524
Mailing Address - Country:US
Mailing Address - Phone:815-723-4387
Mailing Address - Fax:815-723-4634
Practice Address - Street 1:1890 SILVER CROSS BLVD
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451
Practice Address - Country:US
Practice Address - Phone:815-723-4387
Practice Address - Fax:815-723-4634
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0987562084N0400X
MDD630532084V0102X
DCMD0353722084V0102X
IL0361338252084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0319247Medicaid
IL036133825Medicaid
ILCA4748OtherMEDICARE RAILROAD (GROUP)
ILF400099637OtherMEDICARE (INDIVIDUAL PTAN)
IL206147OtherMEDICARE (GROUP PTAN)
OH0319247Medicaid