Healthcare Provider Details

I. General information

NPI: 1679648315
Provider Name (Legal Business Name): DAVID EDWIN BURDETTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2531
US

IV. Provider business mailing address

100 MICHIGAN ST NE # MC845
GRAND RAPIDS MI
49503-2560
US

V. Phone/Fax

Practice location:
  • Phone: 616-267-7900
  • Fax: 616-267-7901
Mailing address:
  • Phone: 616-486-6790
  • Fax: 616-486-6702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number4301056700
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number4301056700
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: