Healthcare Provider Details

I. General information

NPI: 1174712723
Provider Name (Legal Business Name): KRAIG M. BURGESS, D. O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15830 N 35TH AVE
PHOENIX AZ
85053-7640
US

IV. Provider business mailing address

15830 N 35TH AVE
PHOENIX AZ
85053-7640
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-1188
  • Fax: 602-866-0810
Mailing address:
  • Phone: 602-298-1188
  • Fax: 602-866-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number4169
License Number StateAZ

VIII. Authorized Official

Name: KRAIG M BURGESS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 602-298-1188