Provider Demographics
NPI:1831182336
Name:BURGESS, RUSSELL E (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:BURGESS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-633-1010
Mailing Address - Fax:252-224-3071
Practice Address - Street 1:137 MEDICAL LANE
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573
Practice Address - Country:US
Practice Address - Phone:252-633-1010
Practice Address - Fax:252-224-3071
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19319207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC131F9OtherBLUE CROSS
NC89131F9Medicaid
NCP00200891Medicare PIN
NC89131F9Medicaid
NC2299624BMedicare ID - Type Unspecified