Provider Demographics
NPI:1699745190
Name:BURGESS, STEPHEN B (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
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 1:1552 PRANCER CT
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-1685
Mailing Address - Country:US
Mailing Address - Phone:704-865-5139
Mailing Address - Fax:
Practice Address - Street 1:1552 PRANCER CT
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28056-1685
Practice Address - Country:US
Practice Address - Phone:704-865-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900444207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH00346Medicare UPIN