MEDICARE: MICHELLE BURGESS PAC

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	363A00000X	Physician Assistant	885	MA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	808005	OTHER	MA	CONNECTICARE

General Provider Information

NPI Number	:	1508835018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE BURGESS PAC

Provider Business Mailing Address
First Line	:	235 GREENFIELD RD
Second Line	:
City	:	SOUTH DEERFIELD
State	:	MA
Zip	:	01373-9790
Country	:	US
Telephone Number	:	413-665-2099
Fax Number	:	413-665-5189

Provider Business Practice Location Address
First Line	:	235 GREENFIELD RD
Second Line	:
City	:	SOUTH DEERFIELD
State	:	MA
Zip	:	01373-9790
Country	:	US
Telephone Number	:	413-665-2099
Fax Number	:	413-665-5189

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

Provider Enumeration Date	:	03/16/2006
Last Update Date	:	07/08/2007

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Directions to “ MICHELLE BURGESS PAC” Practice Location

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