Basic Information
| Provider Information | |||||||||
| NPI: | 1396843231 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURGO-BLACK | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | LUCILE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BURGO | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LUCILE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 20 KENTER PL | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065152412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033896335 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | VACT HEALTHCARE SYSTEM | ||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | 2039373403 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 025451 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.