Healthcare Provider Details

I. General information

NPI: 1497286629
Provider Name (Legal Business Name): KYLE BRIAN BURGHGRAEF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5030 N WALNUT ST
SOUTH BLOOMFIELD OH
43103-1018
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 740-983-0015
  • Fax: 740-983-4763
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number35139089
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35139089
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: