Healthcare Provider Details

I. General information

NPI: 1649340530
Provider Name (Legal Business Name): RICHARD ELY BURGESS M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2130 W CENTRAL AVE STE 102103
TOLEDO OH
43606-3818
US

IV. Provider business mailing address

3000 ARLINGTON AVE STOP 1108
TOLEDO OH
43614-2595
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-3900
  • Fax:
Mailing address:
  • Phone: 419-383-5023
  • Fax: 419-383-6235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberMD035372
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberD63053
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number036133825
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35.098756
License Number StateOH
# 5
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number35.098756
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: