Healthcare Provider Details

I. General information

NPI: 1669673679
Provider Name (Legal Business Name): MARY BROOKE BURGE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 08/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

2840 SHIPPING AVE
MIAMI FL
33133-4616
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-6973
  • Fax:
Mailing address:
  • Phone: 305-812-3447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN10359
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME107528
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: