Basic Information
| Provider Information | |||||||||
| NPI: | 1306812839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURGESS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DAVID | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 WESTCHESTER AVE | ||||||||
| Address2: | L 22 | ||||||||
| City: | PORT CHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105733853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149376194 | ||||||||
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| Practice Location | |||||||||
| Address1: | ST. BARNABAS HOSPITAL, DEPARTMENT OF PSYCHIATRY | ||||||||
| Address2: | 183RD ST. AND 3RD AVE. | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189606159 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 127526 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 00237229 | 05 | NY | MEDICAID |