Healthcare Provider Details

I. General information

NPI: 1780650283
Provider Name (Legal Business Name): MATTHEW O BURRELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

IV. Provider business mailing address

759 OLD NORCROSS RD
LAWRENCEVILLE GA
30046-4317
US

V. Phone/Fax

Practice location:
  • Phone: 404-300-2379
  • Fax: 404-300-2379
Mailing address:
  • Phone: 404-300-2379
  • Fax: 404-300-2379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number017998
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: