Basic Information
| Provider Information | |||||||||
| NPI: | 1962496661 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURKHEAD | ||||||||
| FirstName: | SUSANNA | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 359 | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477030359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124851220 | ||||||||
| FaxNumber: | 8124858544 | ||||||||
| Practice Location | |||||||||
| Address1: | 3700 WASHINGTON AVENUE | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477500001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124854000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | 01066004A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100111320 | 05 | KY | MEDICAID | 200978080 | 05 | IN | MEDICAID |