Basic Information
| Provider Information | |||||||||
| NPI: | 1205862679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURLISON | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WOLFE | ||||||||
| OtherFirstName: | KATHLEEN | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 111 BEACH RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032597442 | ||||||||
| FaxNumber: | 2032595108 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 BEACH RD | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032597442 | ||||||||
| FaxNumber: | 2032595108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/01/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 039435 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.