Basic Information
| Provider Information | |||||||||
| NPI: | 1801839873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURT | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646253 | ||||||||
| FaxNumber: | 5173646208 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 E COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488541381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172448900 | ||||||||
| FaxNumber: | 5172448911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 5101009546 | MI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0153300815 | 01 | MI | BCBS INDIVIDUAL PIN | OTHER |