Provider Demographics
NPI:1194767178
Name:BURGESS, ANNE PATRICE (MD)
Entity type:Individual
Prefix:DR
First Name:ANNE
Middle Name:PATRICE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:PATRICE
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-7205
Mailing Address - Fax:208-367-7204
Practice Address - Street 1:10255 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1430
Practice Address - Country:US
Practice Address - Phone:208-367-7205
Practice Address - Fax:208-367-7204
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1137100Medicare PIN
F02327Medicare UPIN
ID003601400Medicaid
ID11371002Medicare PIN