Provider Demographics
NPI:1104877679
Name:GERALD C BURNETT MD LTD
Entity type:Organization
Organization Name:GERALD C BURNETT MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:CRAIN
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-572-6780
Mailing Address - Street 1:405 OAK LANE
Mailing Address - Street 2:PO BOX 835
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-0835
Mailing Address - Country:US
Mailing Address - Phone:434-572-6780
Mailing Address - Fax:434-572-6033
Practice Address - Street 1:405 OAK LANE
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-0835
Practice Address - Country:US
Practice Address - Phone:434-572-6780
Practice Address - Fax:434-572-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101017885207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B06223Medicare UPIN
VA071888825Medicare ID - Type Unspecified
VAC10368Medicare PIN