Basic Information
| Provider Information | |||||||||
| NPI: | 1528160371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURSTEDT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 S WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313727716 | ||||||||
| FaxNumber: | 9313727717 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 S WILLOW AVE | ||||||||
| Address2: | |||||||||
| City: | COOKEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385014667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313727716 | ||||||||
| FaxNumber: | 9313720087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2006 | ||||||||
| LastUpdateDate: | 08/27/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | BP10053739 | TX | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | 11069136-1205 | UT | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 174400000X | RPT-1815 | ID | N | Other Service Providers | Specialist | 207LP2900X | 61181 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q059073 | 05 | TN | MEDICAID |