Healthcare Provider Details

I. General information

NPI: 1104604305
Provider Name (Legal Business Name): JACK CHRISTOPHER BURG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5577 MONROE ST STE A1
SYLVANIA OH
43560-2565
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 419-318-8104
  • Fax: 419-540-9067
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501302987
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT020177
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: