Healthcare Provider Details

I. General information

NPI: 1306885157
Provider Name (Legal Business Name): EDWARD BURKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 08/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 W MAIN ST
FREDERICKTOWN MO
63645-1113
US

IV. Provider business mailing address

735 W MAIN ST
FREDERICKTOWN MO
63645-1113
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-8875
  • Fax: 573-783-8890
Mailing address:
  • Phone: 573-783-8875
  • Fax: 573-783-8890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036099747
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010023551
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2010023551
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: