Healthcare Provider Details

I. General information

NPI: 1972593515
Provider Name (Legal Business Name): MR. JEFFREY A. BURK
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 GREENFIELD RD
BLOOMINGTON IL
61704-8421
US

IV. Provider business mailing address

2814 GREENFIELD RD
BLOOMINGTON IL
61704-8421
US

V. Phone/Fax

Practice location:
  • Phone: 309-662-2632
  • Fax: 309-662-7852
Mailing address:
  • Phone: 309-662-2632
  • Fax: 309-662-7852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberTR00196
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: