MEDICARE: DR. CAROL MARIE BURCH MD

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	207Q00000X	Family Medicine Physician	G76903	CA

General Provider Information

NPI Number	:	1356360721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROL MARIE BURCH MD

Provider Business Mailing Address
First Line	:	3400 DATA DR
Second Line	:	ATTN CREDENTIALING/PAYER ENROLLMENT
City	:	RANCHO CORDOVA
State	:	CA
Zip	:	95670
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3132 W MARCH LN STE 5
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95219-2354
Country	:	US
Telephone Number	:	209-475-5500
Fax Number	:	209-475-5535

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

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	06/16/2021

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