Provider Demographics
NPI:1811980030
Name:BURDEN, THEODORE (MD)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:BURDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 820933
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-0933
Mailing Address - Country:US
Mailing Address - Phone:215-926-9022
Mailing Address - Fax:215-226-8286
Practice Address - Street 1:2100 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-1400
Practice Address - Country:US
Practice Address - Phone:215-685-0800
Practice Address - Fax:215-685-0846
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020774E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000804021Medicaid
PA1019558OtherKEYSTONE MERCY HEALTH
PAP00037862OtherRAILROAD MEDICARE
PA0054331000OtherINDEPENDENCE BLUE CROSS
PA128306OtherHIGHMARK BLUE SHIELD
PA597586OtherMEDICARE GROUP
PACD4829OtherRAILROAD MEDICARE TPI GROUP
PA0054331000OtherINDEPENDENCE BLUE CROSS
PA1019558OtherKEYSTONE MERCY HEALTH