Healthcare Provider Details

I. General information

NPI: 1477510543
Provider Name (Legal Business Name): HARRY RUSSELL BURGER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2006
Last Update Date: 01/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12127 B HWY 14 N STE 5
CEDAR CREST NM
87008-9461
US

IV. Provider business mailing address

12127B HWY 14 N STE 5
CEDAR CREST NM
87008-9461
US

V. Phone/Fax

Practice location:
  • Phone: 505-281-2460
  • Fax: 505-281-2463
Mailing address:
  • Phone: 505-281-2460
  • Fax: 505-281-2463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberA122403
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA122403
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA-1224-03
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: