Healthcare Provider Details

I. General information

NPI: 1669503090
Provider Name (Legal Business Name): WILLIAM R BURGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 STOCKTON HILL RD
KINGMAN AZ
86409-3619
US

IV. Provider business mailing address

PO BOX 73878
SAN CLEMENTE CA
92673-0130
US

V. Phone/Fax

Practice location:
  • Phone: 928-753-7776
  • Fax:
Mailing address:
  • Phone: 714-754-5800
  • Fax: 714-754-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number32154
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number32154
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: