Basic Information
| Provider Information | |||||||||
| NPI: | 1740391606 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURD | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | A, | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 504407 | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631504407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169327940 | ||||||||
| FaxNumber: | 8169327957 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 BROADWAY ST | ||||||||
| Address2: | SUITE 407 | ||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641113498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169321711 | ||||||||
| FaxNumber: | 8169321719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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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 | 2084P0800X | 2005004431 | MO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | 04-26995 | KS | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 207395500 | 05 | MO | MEDICAID |