Healthcare Provider Details

I. General information

NPI: 1548256779
Provider Name (Legal Business Name): CAROL J BURGESS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL DR
BENNINGTON VT
05201-5004
US

IV. Provider business mailing address

1444 WESTERN AVE SUITE B-1
ALBANY NY
12203-3462
US

V. Phone/Fax

Practice location:
  • Phone: 802-442-6361
  • Fax:
Mailing address:
  • Phone: 518-458-2611
  • Fax: 518-489-1914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number159113
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: