Healthcare Provider Details

I. General information

NPI: 1417179714
Provider Name (Legal Business Name): KRISTINE BURKE MD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 02/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 E BIDWELL ST STE 100
FOLSOM CA
95630-3873
US

IV. Provider business mailing address

2390 E. BIDWELL STREET SUITE 100
FOLSOM CA
95630
US

V. Phone/Fax

Practice location:
  • Phone: 916-983-5771
  • Fax: 916-983-6004
Mailing address:
  • Phone: 916-983-5771
  • Fax: 916-983-6004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG079569
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberG079569
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License NumberG79569
License Number StateCA

VIII. Authorized Official

Name: KRISTINE LOUISE BURKE
Title or Position: PRESIDENT
Credential:
Phone: 916-983-5771