Provider Demographics
NPI:1750414306
Name:JOHN J BURROUGHS MD PC
Entity type:Organization
Organization Name:JOHN J BURROUGHS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:BURROUGHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-241-3543
Mailing Address - Street 1:2200 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4254
Mailing Address - Country:US
Mailing Address - Phone:734-241-3543
Mailing Address - Fax:734-241-4726
Practice Address - Street 1:2200 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4254
Practice Address - Country:US
Practice Address - Phone:734-241-3543
Practice Address - Fax:734-241-4726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00581292OtherBCBSM
MIJB022044OtherLICENSE #
MIA74748Medicare UPIN
MI0581292Medicare ID - Type UnspecifiedMEDICARE