Basic Information
| Provider Information | |||||||||
| NPI: | 1861476285 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURT | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8333 NAAB RD | ||||||||
| Address2: | STE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3178764070 | ||||||||
| Practice Location | |||||||||
| Address1: | 8333 NAAB RD | ||||||||
| Address2: | STE 250 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462605924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173961300 | ||||||||
| FaxNumber: | 3178764070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2005 | ||||||||
| LastUpdateDate: | 10/10/2008 | ||||||||
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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 | 207T00000X | 01022687A | IN | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 100318270 | 05 | IN | MEDICAID |