Basic Information
| Provider Information | |||||||||
| NPI: | 1174808638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | BRYCE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613606 | ||||||||
| FaxNumber: | 6015795240 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S 28TH AVE | ||||||||
| Address2: | |||||||||
| City: | HATTIESBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 394017246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012613606 | ||||||||
| FaxNumber: | 6015795383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2011 | ||||||||
| LastUpdateDate: | 08/23/2016 | ||||||||
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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 | 390200000X | R877664 | MS | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | 3007275 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | A810475 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 3539043 | 01 | MS | UNITED HEALTHCARE | OTHER | 9758895 | 01 | MS | AETNA | OTHER | 8318378 | 01 | MS | CIGNA | OTHER | 01235096 | 05 | MS | MEDICAID |