Provider Demographics
NPI:1912510033
Name:BURKE, DEMETRIUS (QIDP,)
Entity type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:
Last Name:BURKE
Suffix:
Gender:
Credentials:QIDP,
Other - Prefix:
Other - First Name:DEMETRIUS
Other - Middle Name:ALEXANDRA
Other - Last Name:BURKE-HAGERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DEMETRIUS BURKE
Mailing Address - Street 1:3769 QUARTON RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-4058
Mailing Address - Country:US
Mailing Address - Phone:248-894-1966
Mailing Address - Fax:
Practice Address - Street 1:3769 QUARTON RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-4058
Practice Address - Country:US
Practice Address - Phone:248-894-1966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1912510033Medicaid