MEDICARE: MRS. UREKA BURNETT EVAN

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	174400000X	Specialist	SSC00402009-0076	GA

General Provider Information

NPI Number	:	1568789253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. UREKA BURNETT EVAN

Provider Business Mailing Address
First Line	:	6126 KATHERINE RD
Second Line	:
City	:	REX
State	:	GA
Zip	:	30273-1119
Country	:	US
Telephone Number	:	404-444-4684
Fax Number	:	678-565-1454

Provider Business Practice Location Address
First Line	:	667 FAIRBURN RD NW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-1423
Country	:	US
Telephone Number	:	404-444-4684
Fax Number	:	678-565-1454

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

Provider Enumeration Date	:	04/21/2010
Last Update Date	:	04/21/2010

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