Basic Information
| Provider Information | |||||||||
| NPI: | 1043201361 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 33369 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282333369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043648100 | ||||||||
| FaxNumber: | 7043652073 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 VAIL AVENUE | ||||||||
| Address2: | STE 320 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043330741 | ||||||||
| FaxNumber: | 7043333356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 200200093 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 200200093 | NC | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 891305A | 05 | NC | MEDICAID | 2000396D | 01 | MEDICARE PIN FACULTY | OTHER | 2000396 | 01 | MEDICARE | OTHER |