Healthcare Provider Details

I. General information

NPI: 1235113408
Provider Name (Legal Business Name): JEREMY J BURDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 OLENTANGY RIVER RD SUITE C
COLUMBUS OH
43214-3449
US

IV. Provider business mailing address

3732 OLENTANGY RIVER RD SUITE C
COLUMBUS OH
43214-3449
US

V. Phone/Fax

Practice location:
  • Phone: 614-451-0411
  • Fax: 614-451-8037
Mailing address:
  • Phone: 614-451-0411
  • Fax: 614-451-8037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number35-042744
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35.042744
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: