Provider Demographics
NPI:1194879452
Name:BURGESS, SALLY ELAINE (MD)
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:ELAINE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:996 MEDICAL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:SC
Mailing Address - Zip Code:29325-4541
Mailing Address - Country:US
Mailing Address - Phone:864-833-5654
Mailing Address - Fax:864-833-2786
Practice Address - Street 1:996 MEDICAL RIDGE RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-4541
Practice Address - Country:US
Practice Address - Phone:864-833-5654
Practice Address - Fax:864-833-2786
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC152Medicaid
SC229522Medicaid
SC1083652630OtherGROUP NPI #
SCGP1856Medicaid