Basic Information
| Provider Information | |||||||||
| NPI: | 1538104773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURDEAUX | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1225 E WEISGARBER RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379092604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655844747 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2545 JACKSBORO PIKE | ||||||||
| Address2: | |||||||||
| City: | JACKSBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377574847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235668181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 07/17/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1037 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3303722 | 05 | TN | MEDICAID | P00060330 | 01 | TN | RR MEDICARE | OTHER |