Basic Information
| Provider Information | |||||||||
| NPI: | 1124045752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURNSIDE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D., MBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 REMIT DRIVE | ||||||||
| Address2: | LOCKBOX 1876 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606751876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669165259 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620026722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184637311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
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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 | 207P00000X | 036-090895 | IL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 2666 | KY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 107364 | MO | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25.067203 | OH | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 208063727 | 05 | MO | MEDICAID | 036090895 | 05 | IL | MEDICAID | 036090895-3 | 05 | IL | MEDICAID |