Basic Information
| Provider Information | |||||||||
| NPI: | 1457307381 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE BURGOYNE INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94448 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850704448 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808624427 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Practice Location | |||||||||
| Address1: | 4055 W CHANDLER BLVD | ||||||||
| Address2: | STE 5 | ||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852263732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804644431 | ||||||||
| FaxNumber: | 4804642338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 12/04/2007 | ||||||||
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| AuthorizedOfficialLastName: | BURGOYNE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | SIDNEY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4804644431 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.