Basic Information
| Provider Information | |||||||||
| NPI: | 1205213246 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURCH | ||||||||
| FirstName: | ADAM | ||||||||
| MiddleName: | NIELSEN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742358 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742358 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2280 E 25TH ST | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834047542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082272100 | ||||||||
| FaxNumber: | 2082272362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2015 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | O-1364 | ID | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.