Healthcare Provider Details

I. General information

NPI: 1619947405
Provider Name (Legal Business Name): RICHARD KEITH BURWELL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MEDICAL GROUP 45 PINE ROAD
LANGLEY AFB VA
23665-2080
US

IV. Provider business mailing address

1ST MEDICAL GROUP 45 PINE ROAD
LANGLEY AFB VA
23665-2080
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-6090
  • Fax: 757-225-1411
Mailing address:
  • Phone: 757-764-6090
  • Fax: 757-225-1411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0102033533
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: