Basic Information
| Provider Information | |||||||||
| NPI: | 1023646825 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURRISS-WEST | ||||||||
| FirstName: | MARYBETH | ||||||||
| MiddleName: | ARCEO | ||||||||
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| OtherLastName: | BURRISS | ||||||||
| OtherFirstName: | MARYBETH | ||||||||
| OtherMiddleName: | ARCEO | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4008 LILA BLUE LN | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276126955 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192740821 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD FL 4 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043816800 | ||||||||
| FaxNumber: | 7043816841 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2020 | ||||||||
| LastUpdateDate: | 03/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 261027 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.