Healthcare Provider Details

I. General information

NPI: 1306807359
Provider Name (Legal Business Name): MARY KAY BURRIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S CHIPETA WAY
SALT LAKE CITY UT
84108-1222
US

IV. Provider business mailing address

PO BOX 413076
SALT LAKE CITY UT
84141-3076
US

V. Phone/Fax

Practice location:
  • Phone: 801-585-1575
  • Fax:
Mailing address:
  • Phone: 801-213-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number6019908-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: