Basic Information
| Provider Information | |||||||||
| NPI: | 1306595657 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGEI | ||||||||
| FirstName: | MADISON | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD | ||||||||
| Address2: | BUILDING B 2ND FLOOR | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 E APPLE ST STE 5254 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454092939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372084200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2022 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 50.007509RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.