Basic Information
| Provider Information | |||||||||
| NPI: | 1023080991 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
| FaxNumber: | 6164646170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 LEFFINGWELL AVE NE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495256406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164597101 | ||||||||
| FaxNumber: | 6164646170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 07/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4301087092 | MI | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 4301087092 | MI | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 208600000X | 4301087092 | MI | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0105X | 4301087092 | MI | N | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand |
ID Information
| ID | Type | State | Issuer | Description | 4834931 | 05 | MI | MEDICAID |