=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417048596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID GLENN BURCHUK P.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2006
-----------------------------------------------------
Last Update Date | 07/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 CATE ST
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03801-7108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-431-0277
-----------------------------------------------------
Fax | 603-422-8849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29 GARRISON LN
-----------------------------------------------------
City | MADBURY
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03823-7605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-749-6496
-----------------------------------------------------
Fax | 603-422-8849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1271
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------