MEDICARE: DR. RICHARD TYLER BURGNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	ME139284	FL
2	2085R0202X	Diagnostic Radiology Physician	74713	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053730481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD TYLER BURGNER M.D.

Provider Business Mailing Address
First Line	:	4500 SAN PABLO RD S
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32224-1865
Country	:	US
Telephone Number	:	904-953-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1270 FRIENDSHIP RD
Second Line	:
City	:	BRASELTON
State	:	GA
Zip	:	30517-5608
Country	:	US
Telephone Number	:	770-535-9391
Fax Number	:	770-533-4701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2014
Last Update Date	:	06/15/2022

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