Healthcare Provider Details

I. General information

NPI: 1467472555
Provider Name (Legal Business Name): MICHAEL W BURGESS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W NORTH ST
JACKSON MI
49202-3135
US

IV. Provider business mailing address

PO BOX 67000 DEPT 272801
DETROIT MI
48267-2728
US

V. Phone/Fax

Practice location:
  • Phone: 517-782-2555
  • Fax: 517-782-3399
Mailing address:
  • Phone: 517-841-7490
  • Fax: 517-841-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB009713
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: