Provider Demographics
NPI:1043395825
Name:BURGOON, MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:BURGOON
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 1:2302 COLONIAL AVE SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015
Mailing Address - Country:US
Mailing Address - Phone:540-343-6636
Mailing Address - Fax:540-343-6670
Practice Address - Street 1:2302 COLONIAL AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015
Practice Address - Country:US
Practice Address - Phone:540-343-6636
Practice Address - Fax:540-343-6670
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001967111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
P06008229OtherPALMETTO MEDICARE
292833OtherANTHEM
P06008229OtherPALMETTO MEDICARE