Basic Information
| Provider Information | |||||||||
| NPI: | 1235200510 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGER | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | AMITYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117012137 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2201 HEMPSTEAD TPKE | ||||||||
| Address2: | NASSAU UNIVERSITY MEDICAL CENTER | ||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115541859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726705 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 008882 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 008882 | 01 | NY | NY STATE LICENSE NUMBER | OTHER |