Healthcare Provider Details

I. General information

NPI: 1972897684
Provider Name (Legal Business Name): LOLA J BURKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 MORGANTOWN ST STE 1
KINGWOOD WV
26537-1140
US

IV. Provider business mailing address

150 MEMORIAL DR
KINGWOOD WV
26537-1141
US

V. Phone/Fax

Practice location:
  • Phone: 304-329-7124
  • Fax: 304-329-7092
Mailing address:
  • Phone: 304-329-1400
  • Fax: 304-329-1175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25293
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39113
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number25293
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: