Provider Demographics
NPI:1104420454
Name:BURST, JOSEPH CHARLES
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:CHARLES
Last Name:BURST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7343 COMMONWEALTH DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45224-1413
Mailing Address - Country:US
Mailing Address - Phone:513-390-2773
Mailing Address - Fax:
Practice Address - Street 1:7343 COMMONWEALTH DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45224-1413
Practice Address - Country:US
Practice Address - Phone:513-240-6262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3747P1801X3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0000272862OtherOHIO SHARED SERVICES
OH3124885OtherDODD