Provider Demographics
NPI:1043276389
Name:BURGESS, EDDY D (CRNA)
Entity type:Individual
Prefix:MR
First Name:EDDY
Middle Name:D
Last Name:BURGESS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:851 TRAFALGAR CT.
Mailing Address - Street 2:SUITE 200E
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751
Mailing Address - Country:US
Mailing Address - Phone:407-667-0444
Mailing Address - Fax:407-667-4338
Practice Address - Street 1:8965 EASTON RIVER DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1714
Practice Address - Country:US
Practice Address - Phone:904-588-4347
Practice Address - Fax:904-737-4879
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9167702367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00912458AMedicaid
FLG2681OtherBLUE CROSS BLUE SHIELD
FL303170500Medicaid
G2681Medicare PIN