Provider Demographics
NPI:1306885157
Name:BURKE, EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:BURKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:MO
Mailing Address - Zip Code:63645-1113
Mailing Address - Country:US
Mailing Address - Phone:573-783-8875
Mailing Address - Fax:573-783-8890
Practice Address - Street 1:735 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREDERICKTOWN
Practice Address - State:MO
Practice Address - Zip Code:63645-1113
Practice Address - Country:US
Practice Address - Phone:573-783-8875
Practice Address - Fax:573-783-8890
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099747207R00000X
MO2010023551207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
268942OtherMEDICARE RHC
MO597560408Medicaid
ILG99077Medicare UPIN
MO597560408Medicaid