Basic Information
| Provider Information | |||||||||
| NPI: | 1912048224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKETT | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | W. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2700 STANLEY GAULT PKWY | ||||||||
| Address2: | SUITE 129 | ||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402235132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534900 | ||||||||
| FaxNumber: | 5024895750 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708246655 | ||||||||
| FaxNumber: | 2708246629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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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 | 207XS0117X | 46122 | KY | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Orthopaedic Surgery of the Spine | 207X00000X | 46122 | KY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100133370 | 05 | KY | MEDICAID | 3086913 | 05 | OH | MEDICAID |