Basic Information
| Provider Information | |||||||||
| NPI: | 1396735882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | KRAIG | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80217 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850600217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023852115 | ||||||||
| FaxNumber: | 4804183323 | ||||||||
| Practice Location | |||||||||
| Address1: | 18555 N 79TH AVE STE E101 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026485444 | ||||||||
| FaxNumber: | 6027723801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 4169 | AZ | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0106X | 4169 | AZ | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery |
ID Information
| ID | Type | State | Issuer | Description | 954348 | 05 | AZ | MEDICAID |