Healthcare Provider Details

I. General information

NPI: 1508858200
Provider Name (Legal Business Name): RUSSELL R BURKEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

274 BIG A ROAD
TOCCOA GA
30577-6002
US

IV. Provider business mailing address

274 BIG A ROAD
TOCCOA GA
30577-6002
US

V. Phone/Fax

Practice location:
  • Phone: 706-886-6069
  • Fax: 706-282-5299
Mailing address:
  • Phone: 706-886-6069
  • Fax: 706-282-5299

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number30438
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000363932A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: