Provider Demographics
NPI:1396100780
Name:BURGESS, JAMES GARLAND (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GARLAND
Last Name:BURGESS
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 1:307 NORDIN LN
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72802-9006
Mailing Address - Country:US
Mailing Address - Phone:479-970-5709
Mailing Address - Fax:
Practice Address - Street 1:307 NORDIN LN
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72802-9006
Practice Address - Country:US
Practice Address - Phone:479-970-5709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4094174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR50772Medicare UPIN