Healthcare Provider Details

I. General information

NPI: 1306135744
Provider Name (Legal Business Name): J GORDON BURCH MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4461 STARKEY RD SUITE 101
ROANOKE VA
24018-0620
US

IV. Provider business mailing address

4461 STARKEY RD SUITE 101
ROANOKE VA
24018-0620
US

V. Phone/Fax

Practice location:
  • Phone: 540-342-0211
  • Fax: 540-344-5543
Mailing address:
  • Phone: 540-342-0211
  • Fax: 540-344-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101030765
License Number StateVA

VIII. Authorized Official

Name: DR. J GORDON BURCH
Title or Position: SOLE OWNER
Credential: M.D.
Phone: 540-342-0211