Provider Demographics
NPI:1356340533
Name:BURGE, RAYMOND A (DC)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:BURGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1929 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:IL
Mailing Address - Zip Code:61264
Mailing Address - Country:US
Mailing Address - Phone:309-787-2600
Mailing Address - Fax:309-787-2643
Practice Address - Street 1:1929 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:IL
Practice Address - Zip Code:61264
Practice Address - Country:US
Practice Address - Phone:309-787-2600
Practice Address - Fax:309-787-2643
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
204354Medicare ID - Type Unspecified
L96049Medicare UPIN