Provider Demographics
NPI:1568265189
Name:BURGESS, WILLIAM TROY
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:TROY
Last Name:BURGESS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 DOUGLAS ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920-4519
Mailing Address - Country:US
Mailing Address - Phone:217-218-1763
Mailing Address - Fax:
Practice Address - Street 1:101 W WINDSOR RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-6603
Practice Address - Country:US
Practice Address - Phone:217-344-2144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-29
Last Update Date:2025-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.006193225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant