Provider Demographics
NPI:1174549802
Name:BURGESS, JACQUES (MD)
Entity type:Individual
Prefix:
First Name:JACQUES
Middle Name:
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:PO BOX 27127
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48909-7127
Mailing Address - Country:US
Mailing Address - Phone:231-346-6800
Mailing Address - Fax:231-346-6017
Practice Address - Street 1:1105 SIXTH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2345
Practice Address - Country:US
Practice Address - Phone:231-935-5000
Practice Address - Fax:231-346-6017
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070541208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4234840Medicaid
MI4324722Medicaid
H14649Medicare UPIN
MI4324722Medicaid
B06000048Medicare PIN