Basic Information
| Provider Information | |||||||||
| NPI: | 1811980030 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURDEN | ||||||||
| FirstName: | THEODORE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 820933 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191820933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159269022 | ||||||||
| FaxNumber: | 2152268286 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W GIRARD AVE | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191301400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156850800 | ||||||||
| FaxNumber: | 2156850846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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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 | 207R00000X | MD020774E | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000804021 | 05 | PA | MEDICAID | 1019558 | 01 | PA | KEYSTONE MERCY HEALTH | OTHER | P00037862 | 01 | PA | RAILROAD MEDICARE | OTHER | 0054331000 | 01 | PA | INDEPENDENCE BLUE CROSS | OTHER | 128306 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 597586 | 01 | PA | MEDICARE GROUP | OTHER | CD4829 | 01 | PA | RAILROAD MEDICARE TPI GROUP | OTHER |