Basic Information
| Provider Information | |||||||||
| NPI: | 1023095817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURRIS | ||||||||
| FirstName: | SCOTT | ||||||||
| MiddleName: | BRADLEY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650426 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155007 | ||||||||
| FaxNumber: | 9727155682 | ||||||||
| Practice Location | |||||||||
| Address1: | 13737 NOEL ROAD | ||||||||
| Address2: | SUITE 1400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752402004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9727155000 | ||||||||
| FaxNumber: | 9727159976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 09/20/2013 | ||||||||
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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 | 207L00000X | G9406 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 128023208 | 01 | TX | MEDICAID CSHCN | OTHER | 050065934 | 01 | TX | RAILROAD | OTHER | 128023203 | 05 | TX | MEDICAID | 128023206 | 05 | TX | MEDICAID | 83852K | 01 | TX | BCBS | OTHER | 128023207 | 05 | TX | MEDICAID |