Basic Information
| Provider Information | |||||||||
| NPI: | 1083684179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURDETT | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
| FaxNumber: | 5734262282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733649000 | ||||||||
| FaxNumber: | 5734266694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 208000000X | 9853 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 036118822 | 05 | IL | MEDICAID | 207988 | 01 | IL | GROUP MED | OTHER | 100500798 | 05 | NV | MEDICAID | CE9335 | 01 | IL | RR MEDICARE GRP | OTHER | P00396911 | 01 | RR MEDICARE | OTHER |