MEDICARE: JEREMY J BURDGE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	35-042744	OH
2	208200000X	Plastic Surgery Physician	35.042744	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000118889	OTHER	OH	ANTHEM PROVIDER ID

General Provider Information

NPI Number	:	1235113408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY J BURDGE M.D.

Provider Business Mailing Address
First Line	:	3732 OLENTANGY RIVER RD
Second Line	:	SUITE C
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3449
Country	:	US
Telephone Number	:	614-451-0411
Fax Number	:	614-451-8037

Provider Business Practice Location Address
First Line	:	3732 OLENTANGY RIVER RD
Second Line	:	SUITE C
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3449
Country	:	US
Telephone Number	:	614-451-0411
Fax Number	:	614-451-8037

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	08/30/2013

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