Healthcare Provider Details

I. General information

NPI: 1760291421
Provider Name (Legal Business Name): MR. ROBERT J BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 E 18TH ST
PITTSBURG KS
66762-3348
US

IV. Provider business mailing address

503 E 18TH ST
PITTSBURG KS
66762-3348
US

V. Phone/Fax

Practice location:
  • Phone: 620-641-4460
  • Fax:
Mailing address:
  • Phone: 620-641-4460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: