Provider Demographics
NPI:1972897684
Name:BURKE, LOLA J (MD)
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:J
Last Name:BURKE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537-1141
Mailing Address - Country:US
Mailing Address - Phone:304-329-1400
Mailing Address - Fax:304-329-1175
Practice Address - Street 1:428 MORGANTOWN ST STE 1
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537-1140
Practice Address - Country:US
Practice Address - Phone:304-329-7124
Practice Address - Fax:304-329-7092
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25293207Q00000X, 2084A0401X
SC39113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3810027539Medicaid
WVWV4396B987Medicare PIN