Basic Information
| Provider Information | |||||||||
| NPI: | 1710058482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | JON | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11177 LAMBS LN | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430559779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407630408 | ||||||||
| FaxNumber: | 7407630485 | ||||||||
| Practice Location | |||||||||
| Address1: | 812 COSHOCTON AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430501947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403928811 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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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 | 225100000X | 11052 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2595053 | 05 | OH | MEDICAID |