Healthcare Provider Details

I. General information

NPI: 1013961978
Provider Name (Legal Business Name): ROBERT BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 05/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MINNESOTA ST SUITE 210
RAPID CITY SD
57701-7756
US

IV. Provider business mailing address

2820 MOUNT RUSHMORE RD
RAPID CITY SD
57701-5462
US

V. Phone/Fax

Practice location:
  • Phone: 605-342-3280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4820
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: