Basic Information
| Provider Information | |||||||||
| NPI: | 1548220817 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNS | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 CHAMBER CENTER DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | LAKESIDE PARK | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410171686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596554111 | ||||||||
| FaxNumber: | 8596554814 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 JAMES SIMPSON JR WAY | ||||||||
| Address2: | STE 201 | ||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410110801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8596554111 | ||||||||
| FaxNumber: | 8596554815 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 11/11/2015 | ||||||||
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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 | 207Q00000X | 24790 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64247901 | 05 | KY | MEDICAID | 2159140 | 01 | OH | MEDICAID | OTHER |