Basic Information
| Provider Information | |||||||||
| NPI: | 1730186099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURDETTE | ||||||||
| FirstName: | MARVIN | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 369 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296480369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642272020 | ||||||||
| FaxNumber: | 8642272823 | ||||||||
| Practice Location | |||||||||
| Address1: | 665 WEST ALEXANDER ROAD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642272020 | ||||||||
| FaxNumber: | 8642272823 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/01/2005 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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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 | 207W00000X | 9229 | SC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 092296 | 05 | SC | MEDICAID | PA0515 | 05 | SC | MEDICAID | 180012150 | 01 | SC | RAILROAD MEDICARE | OTHER | CE6166 | 01 | SC | RAILROAD MEDICARE GROUP | OTHER |