Provider Demographics
NPI:1285903146
Name:BURGESS, BRIAN JOHN (DPM)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JOHN
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:HINSDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60521-3186
Mailing Address - Country:US
Mailing Address - Phone:630-323-6116
Mailing Address - Fax:630-323-5309
Practice Address - Street 1:2940 ROLLINGRIDGE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-4231
Practice Address - Country:US
Practice Address - Phone:630-579-6500
Practice Address - Fax:630-579-5860
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL135-000678213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016005467Medicaid
IL016005467Medicaid