Healthcare Provider Details

I. General information

NPI: 1104476977
Provider Name (Legal Business Name): JEFFREY BURGESS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2019
Last Update Date: 11/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 DESALES AVE
CHATTANOOGA TN
37404-1161
US

IV. Provider business mailing address

2341 MCCALLIE AVE
CHATTANOOGA TN
37404-3239
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-2525
  • Fax:
Mailing address:
  • Phone: 423-698-3309
  • Fax: 423-624-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0000026641
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number171605
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: