Basic Information
Provider Information | |||||||||
NPI: | 1538189105 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURNHAM | ||||||||
FirstName: | STEVEN | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4020 WESTCHASE BLVD | ||||||||
Address2: | SUITE 390 | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276073938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9198342767 | ||||||||
FaxNumber: | 9198340234 | ||||||||
Practice Location | |||||||||
Address1: | 3643 N ROXBORO ST | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277042702 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9194705272 | ||||||||
FaxNumber: | 9194705271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 11/06/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 22689 | NC | Y |   | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
ID | Type | State | Issuer | Description | 8920185 | 05 | NC |   | MEDICAID |