Basic Information
| Provider Information | |||||||||
| NPI: | 1073617544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNS | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH KOLD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 CHILDRENS WAY | ||||||||
| Address2: | 807 CHILDRENS WAY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046973600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 49938 | MN | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP3000X | ME112496 | FL | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 003124507A | 05 | GA | MEDICAID | 858113000 | 05 | MN | MEDICAID | 006234600 | 05 | FL | MEDICAID |