Provider Demographics
NPI:1255435566
Name:BURGESS, MICHELE J (MD)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:J
Last Name:BURGESS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1733 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60707
Mailing Address - Country:US
Mailing Address - Phone:773-237-6666
Mailing Address - Fax:773-237-7350
Practice Address - Street 1:1733 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60707
Practice Address - Country:US
Practice Address - Phone:773-237-6666
Practice Address - Fax:773-237-7350
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H89366Medicare UPIN
K11396Medicare ID - Type Unspecified