Provider Demographics
NPI:1124062757
Name:BURK, TERRY J (MD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:J
Last Name:BURK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 790051
Mailing Address - Street 2:MARYVILLE RADIOLOGY GROUP LTD
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63179-0051
Mailing Address - Country:US
Mailing Address - Phone:314-821-5600
Mailing Address - Fax:314-821-2180
Practice Address - Street 1:6800 STATE ROUTE 162
Practice Address - Street 2:ANDERSON HOSPITAL DEPT OF RADIOLOGY
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-1000
Practice Address - Country:US
Practice Address - Phone:618-288-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
163928OtherGHP
1601347OtherUHC
447052OtherHEALTHLINK
IL0361022781Medicaid
447052OtherHEALTHLINK
163928OtherGHP