Basic Information
| Provider Information | |||||||||
| NPI: | 1588843239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARLES J. BURCH, M.D., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4458 MEDICAL DR STE 505 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106907400 | ||||||||
| FaxNumber: | 2106907405 | ||||||||
| Practice Location | |||||||||
| Address1: | 4458 MEDICAL DR STE 505 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2106907400 | ||||||||
| FaxNumber: | 2106907405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | BURCH | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2106907400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | K2657 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 160409201 | 05 | TX | MEDICAID |