Healthcare Provider Details

I. General information

NPI: 1366488710
Provider Name (Legal Business Name): MARK HAROLD BURGE PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2872 ACTON RD
BIRMINGHAM AL
35243-2502
US

IV. Provider business mailing address

2872 ACTON RD
BIRMINGHAM AL
35243-2502
US

V. Phone/Fax

Practice location:
  • Phone: 205-967-3660
  • Fax: 205-967-3664
Mailing address:
  • Phone: 205-967-3660
  • Fax: 205-967-3664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number905
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1394
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: