Provider Demographics
NPI:1841649357
Name:BURCHELL, PATRICK (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:BURCHELL
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 1:4445 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-3739
Mailing Address - Country:US
Mailing Address - Phone:513-569-3741
Mailing Address - Fax:
Practice Address - Street 1:1945 CEI DR
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-5664
Practice Address - Country:US
Practice Address - Phone:513-984-5133
Practice Address - Fax:513-984-4240
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2020-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY53655207W00000X
IN01083585A207W00000X
OH35138792207W00000X
WAML60658831390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0396040Medicaid
KY7100496340Medicaid