MEDICARE: KELLY GILTHORPE BURKENSTOCK 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	207R00000X	Internal Medicine Physician	023319	LA

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	:	1730183112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY GILTHORPE BURKENSTOCK MD

Provider Business Mailing Address
First Line	:	2040 N CAUSEWAY BLVD
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471
Country	:	US
Telephone Number	:	985-727-7676
Fax Number	:	985-727-3476

Provider Business Practice Location Address
First Line	:	6600 FLEUR DE LIS DR
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70124-1430
Country	:	US
Telephone Number	:	504-888-2829
Fax Number	:	504-888-7439

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	07/19/2022

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