MEDICARE: TYRISA BURDINE SPECIALIST

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	1744P3200X	Prosthetics Case Management	CO131275	GA

General Provider Information

NPI Number	:	1184201782
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRISA BURDINE SPECIALIST

Provider Business Mailing Address
First Line	:	351 THORNTON RD STE 118
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-1589
Country	:	US
Telephone Number	:	865-455-8410
Fax Number	:

Provider Business Practice Location Address
First Line	:	351 THORNTON RD STE 118
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-1589
Country	:	US
Telephone Number	:	865-455-8410
Fax Number	:

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

Provider Enumeration Date	:	03/28/2021
Last Update Date	:	03/28/2021

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Directions to “ TYRISA BURDINE SPECIALIST” Practice Location

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