Provider Demographics
NPI:1841492931
Name:BURGDORF, MICHAEL ROGER (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROGER
Last Name:BURGDORF
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 BEDFORD AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2505
Mailing Address - Country:US
Mailing Address - Phone:615-567-5716
Mailing Address - Fax:615-567-5723
Practice Address - Street 1:3803 BEDFORD AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2505
Practice Address - Country:US
Practice Address - Phone:615-567-5716
Practice Address - Fax:615-567-5723
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN448382086S0122X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3041719Medicare PIN