Healthcare Provider Details

I. General information

NPI: 1700810454
Provider Name (Legal Business Name): TYLER M BURPEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E IDAHO ST STE 316
BOISE ID
83712-6267
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7310
  • Fax:
Mailing address:
  • Phone: 208-381-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number228002
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD0004285
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberM11332
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: