Healthcare Provider Details

I. General information

NPI: 1407593536
Provider Name (Legal Business Name): HALEY BURDGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 05/19/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 MCCLENNAN BANKS DR
CHARLESTON SC
29401-1164
US

IV. Provider business mailing address

169 ASHLEY AVENUE ROOM 202 MAIN HOSPITAL, MSC333
CHARLESTON SC
29425
US

V. Phone/Fax

Practice location:
  • Phone: 516-477-3939
  • Fax:
Mailing address:
  • Phone: 843-792-8972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberLL87707
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: