Provider Demographics
NPI:1881774412
Name:BURGESS, KIM S (MD)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:S
Last Name:BURGESS
Suffix:
Gender:F
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 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:4001 LONG PRAIRIE RD
Practice Address - Street 2:SUITE 140
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028-1525
Practice Address - Country:US
Practice Address - Phone:972-691-2388
Practice Address - Fax:972-691-2766
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7314208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX104490103Medicaid
TX5286394OtherAENTA PIN
TX104490104OtherCSHCN
TX82630SOtherBCBSTX IND PIN
TXBURKG30691OtherCCHIP PIN
1750369203OtherGRP NPI NUMBER
TX5476021OtherCIGNA PIN
TX1407233OtherUHC PIN
TX1088007OtherFIRSTHEALTH PIN
TX00U87ZOtherBCBSTX GRP PIN
TX400061OtherPHCS PIN
TXBURKG30691OtherCCHIP PIN
TX1407233OtherUHC PIN