Basic Information
| Provider Information | |||||||||
| NPI: | 1619978418 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCHELL | ||||||||
| FirstName: | DEL | ||||||||
| MiddleName: | A | ||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593410288 | ||||||||
| FaxNumber: | 8593417482 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 CHANCELLOR DR | ||||||||
| Address2: | |||||||||
| City: | CRESTVIEW HILLS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410175427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593410288 | ||||||||
| FaxNumber: | 8593417482 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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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 | 174400000X | 20063 | KY | N | Other Service Providers | Specialist | 207R00000X | 20063 | KY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 64200637 | 05 | KY | MEDICAID | 021036000 | 01 | FEDERAL BLACK LUNG | OTHER | 000000044592 | 01 | ANTHEM | OTHER | 0420677 | 01 | UNITED HEALTHCARE | OTHER | 0563466 | 05 | OH | MEDICAID | 637091 | 01 | AETNA | OTHER | P00922863 | 01 | KY | RAIL ROAD MEDICARE | OTHER | 50006693 | 01 | PASSPORT | OTHER |