Healthcare Provider Details

I. General information

NPI: 1871771212
Provider Name (Legal Business Name): KENT R. BURRESS, DPM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 08/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1819 WASHINGTON AVE
EVANSVILLE IN
47714-2159
US

IV. Provider business mailing address

1819 WASHINGTON AVE
EVANSVILLE IN
47714-2159
US

V. Phone/Fax

Practice location:
  • Phone: 812-477-0200
  • Fax: 812-477-1267
Mailing address:
  • Phone: 812-477-0200
  • Fax: 812-477-1267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0700515A
License Number StateIN

VIII. Authorized Official

Name: DR. KENT R BURRESS
Title or Position: OWNER
Credential: DPM
Phone: 812-477-0200