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General NPI Number Information
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NPI Number | 1346208840
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Entity Type | Individual
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Provider Name | GRADY L BURLESON MD
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Gender | Male
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Dates
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Enumeration Date | 05/03/2006
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Last Update Date | 04/16/2009
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Provider Practice Location Address
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Address Line | 1000 MAR WALT DR
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-6708
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Country | US
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Telephone | 850-863-7607
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Fax |
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Provider Business Mailing Address
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Address Line | 228 YACHT CLUB DR NE
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-6422
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Country | US
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Telephone | 904-521-2555
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | ME91868
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License Number State | FL
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