=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619048121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY STEVEN BURKE R.PH., FASCP, CGP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1101 MAIN ST
-----------------------------------------------------
City | HILTON HEAD ISLAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-681-2622
-----------------------------------------------------
Fax | 843-681-9392
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 CLYDE LN
-----------------------------------------------------
City | HILTON HEAD ISLAND
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29926-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-681-6429
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835G0303X
-----------------------------------------------------
Taxonomy Name | Geriatric Pharmacist
-----------------------------------------------------
License Number | 005537
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------