Healthcare Provider Details

I. General information

NPI: 1295729481
Provider Name (Legal Business Name): JEFFREY MARK BURNHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10310 THE GROVE BLVD STE 100
BATON ROUGE LA
70836-6455
US

IV. Provider business mailing address

12916 MORGAN MEADOW AVENUE
BATON ROUGE LA
70818
US

V. Phone/Fax

Practice location:
  • Phone: 225-761-5200
  • Fax: 225-761-5702
Mailing address:
  • Phone: 225-938-9287
  • Fax: 225-237-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number017109
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: