Basic Information
| Provider Information | |||||||||
| NPI: | 1023067816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURRELL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652899415 | ||||||||
| FaxNumber: | 7652893883 | ||||||||
| Practice Location | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 403 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652896381 | ||||||||
| FaxNumber: | 7652893883 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 04/04/2017 | ||||||||
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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 | 208600000X | 01033256A | IN | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200112850 | 05 | IN | MEDICAID | 000000711219 | 01 | IN | ANTHEM | OTHER | P00968535 | 01 | IN | RR MEDICARE | OTHER |