Healthcare Provider Details

I. General information

NPI: 1487652228
Provider Name (Legal Business Name): RICHARD GERALD BURRIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

827 F E SELLERS HWY
MONTICELLO MS
39654-9378
US

IV. Provider business mailing address

PO BOX 728
MONTICELLO MS
39654-0728
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-4648
  • Fax: 601-587-0613
Mailing address:
  • Phone: 601-587-4648
  • Fax: 601-587-0613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number06985
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: