Healthcare Provider Details

I. General information

NPI: 1346899002
Provider Name (Legal Business Name): BRANDON J BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

IV. Provider business mailing address

1101 BALL AVE NE
GRAND RAPIDS MI
49505-5904
US

V. Phone/Fax

Practice location:
  • Phone: 616-456-6571
  • Fax: 616-774-2044
Mailing address:
  • Phone: 616-456-6571
  • Fax: 616-774-2044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: