Basic Information
| Provider Information | |||||||||
| NPI: | 1902169808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | STEPHEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 301 BROWN SPRINGS RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361177005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342734159 | ||||||||
| FaxNumber: | 3342734556 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 MCQUEEN SMITH RD N | ||||||||
| Address2: | |||||||||
| City: | PRATTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360667268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342862999 | ||||||||
| FaxNumber: | 3346137276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD.36181 | AL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 204557 | 05 | AL | MEDICAID | 511-96290 | 01 | AL | BCBS OF ALABAMA | OTHER | 8841312 | 01 | AL | CIGNA | OTHER | P01919417 | 01 | AL | RAILROAD MEDICARE | OTHER | 511-97736 | 01 | AL | BCBS OF ALABAMA | OTHER | Z39181 | 01 | UPIN | OTHER | 1902169808 | 01 | NPI | OTHER | 204555 | 05 | AL | MEDICAID | 102I936812 | 01 | AL | MEDICARE | OTHER | Z39181 | 01 | AL | VIVA HEALTH | OTHER |