Provider Demographics
NPI:1801293865
Name:BURGESS, WILLIAM JASON IV (MS, AT, ATC, CSCS)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JASON
Last Name:BURGESS
Suffix:IV
Gender:M
Credentials:MS, AT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 96TH AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-9721
Mailing Address - Country:US
Mailing Address - Phone:616-748-3129
Mailing Address - Fax:616-748-3196
Practice Address - Street 1:3333 96TH AVE
Practice Address - Street 2:
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-9721
Practice Address - Country:US
Practice Address - Phone:616-748-3129
Practice Address - Fax:616-748-3196
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010012922255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer