Provider Demographics
NPI:1780717546
Name:EDWARD BURNETTA MD LLC
Entity type:Organization
Organization Name:EDWARD BURNETTA MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:610-247-9830
Mailing Address - Street 1:5017 BRITTANY LN
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-2079
Mailing Address - Country:US
Mailing Address - Phone:610-247-9830
Mailing Address - Fax:
Practice Address - Street 1:5017 BRITTANY LN
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-2079
Practice Address - Country:US
Practice Address - Phone:610-247-9830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059218L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0073081140001Medicaid
PAG56140Medicare UPIN
PA0073081140001Medicaid