Healthcare Provider Details

I. General information

NPI: 1912048224
Provider Name (Legal Business Name): BENJAMIN W. BURKETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 03/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 CLINIC DR
MADISONVILLE KY
42431-1661
US

IV. Provider business mailing address

2700 STANLEY GAULT PKWY SUITE 129
LOUISVILLE KY
40223-5132
US

V. Phone/Fax

Practice location:
  • Phone: 270-824-6655
  • Fax: 270-824-6629
Mailing address:
  • Phone: 502-253-4900
  • Fax: 502-489-5750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number46122
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number46122
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: