Healthcare Provider Details
I. General information
NPI: 1225022858
Provider Name (Legal Business Name): CHARLES NICHOLAS BURNS JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 09/09/2005
Last Update Date: 12/10/2020
Certification Date: 12/10/2020
Deactivation Date:
Reactivation Date:
III. Provider practice location address
501 S WASHINGTON AVE STE 1000
SCRANTON PA
18505-3814
US
IV. Provider business mailing address
501 S WASHINGTON AVE STE 1000
SCRANTON PA
18505-3814
US
V. Phone/Fax
- Phone: 570-941-0630
- Fax: 570-230-0013
- Phone: 570-941-0630
- Fax: 570-230-0013
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 174400000X |
| Taxonomy | Specialist |
| License Number | MD019709E |
| License Number State | PA |
| # 2 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2084A0401X |
| Taxonomy | Addiction Medicine (Psychiatry & Neurology) Physician |
| License Number | MD019709E |
| License Number State | PA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 0007978940002 |
| Identifier Type | MEDICAID |
| Identifier State | PA |
| Identifier Issuer | |
| # 2 | |
| Identifier | 0900660001 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | MEDICARE DME |
| # 3 | |
| Identifier | 11762 6365 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | GEISINGER HEALTH PLAN |
| # 4 | |
| Identifier | 072965 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | FIRST PRIORITY HEALTH |
| # 5 | |
| Identifier | 34369 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | BLUE SHIELD |
| # 6 | |
| Identifier | 01042601 |
| Identifier Type | OTHER |
| Identifier State | DC |
| Identifier Issuer | CAPITAL BLUE CROSS |
| # 7 | |
| Identifier | 20010385 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AMERIHEALTH MERCY |
| # 8 | |
| Identifier | 000000075845 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | MEDPLUS |
| # 9 | |
| Identifier | 2Y1004 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | HEALTHNET |
| # 10 | |
| Identifier | 340009441 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | TRAVELER'S RAILROAD MEDIC |
| # 11 | |
| Identifier | 505911 |
| Identifier Type | OTHER |
| Identifier State | PA |
| Identifier Issuer | AETNA US HEALTHCARE |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
