MEDICARE: EMPIRE STATE COLON & RECTAL SURGERY, LLC

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	208600000X	Surgery Physician	275077	NY

General Provider Information

NPI Number	:	1376940072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMPIRE STATE COLON & RECTAL SURGERY, LLC

Provider Business Mailing Address
First Line	:	1928 BAY AVE
Second Line	:	SUITE 200
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6214
Country	:	US
Telephone Number	:	718-676-2449
Fax Number	:	718-676-2450

Provider Business Practice Location Address
First Line	:	1928 BAY AVE
Second Line	:	SUITE 200
City	:	BROOKLYN
State	:	NY
Zip	:	11230-6214
Country	:	US
Telephone Number	:	718-676-2449
Fax Number	:	718-676-2450

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	HANS C BURKHOLDER
Credential	:	MD
Telephone Number	:	718-676-2449

Provider Enumeration Date	:	11/24/2014
Last Update Date	:	02/27/2015

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