Healthcare Provider Details

I. General information

NPI: 1205140704
Provider Name (Legal Business Name): EDMUND BURKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 4TH ST
SAN FRANCISCO CA
94143-2351
US

IV. Provider business mailing address

3701 WILSHIRE BLVD STE 600
LOS ANGELES CA
90010-2814
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-1521
  • Fax:
Mailing address:
  • Phone: 323-361-3550
  • Fax: 323-361-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberA142776
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License NumberA142776
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA142776
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: