Basic Information
| Provider Information | |||||||||
| NPI: | 1841649357 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURCHELL | ||||||||
| FirstName: | PATRICK | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4445 LAKE FOREST DR | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452423739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135693741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1945 CEI DR | ||||||||
| Address2: | |||||||||
| City: | BLUE ASH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452425664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139845133 | ||||||||
| FaxNumber: | 5139844240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 05/17/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 53655 | KY | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 01083585A | IN | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 35138792 | OH | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0396040 | 05 | OH | MEDICAID | 7100496340 | 05 | KY | MEDICAID |