Mary Joan Burgess Investigator

Conway Regional Health System NPI1407011968

Summary

Provider Details

NPI Number 1407011968
Provider Name Mary Joan Burgess
Credential
Specialization
Medical School Name University Of Arkansas College Of Medicine
Graduation Year 2008
Gender F
Entity Type Individual
PAC ID by PECOS 7719025824
Professional Enrollment ID I20140910000994
Enumeration Date 07/24/2008
Last Update Date 08/20/2020

Contact Details

Business Practice address 4301 W MARKHAM ST # 783, Little Rock,
72205-7101 Arkansas View on Google Map
Business Practice phone 501-686-8000
Business Practice fax 501-526-5148
Mailing address 4301 W MARKHAM ST # 783, Little Rock,
72205-7101 Arkansas View on Google Map
Other phone 501-686-8000
Other fax 501-526-5148
Email Address shannonfig@domain.com Reval Email Address
Incorrect information? Update the NPI Details for Mary Joan Burgess Update NPI

Payments

Total Payment Worth

$130.53
from 2 payments in the last 6 years

Total Cash or Cash Equivalent

$0.00
from 0 payments in the last 6 years

Total In-kind Items & Services

$130.53
from 2 payments in the last 6 years

Hospital Affilitation

Conway Regional Health System in Little Rock

Little Rock, Arkansas

Education & Training

University Of Arkansas College Of Medicine

2008

Group Affiliation

Organization Name PECOS PAC ID Members
Conway Regional Medical Center Inc 3173428414 115
Newsletter for Healthcare Professionals

Provider Taxonomy Details

Provider Taxonomy 1
Taxonomy
License No.
E-8677 (Arkansas)
Primary Taxonomy
Taxonomy
License No.
E-8677 (Arkansas)

Reference NPI Information (as per NPPES NPI Record)

Field Name Field Value
NPI 1407011968
10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider.
Entity Type Individual
Code describing the type of health care provider that is being assigned an NPI. Codes are:
  • 1 = (Person): individual human being who furnishes health care;
  • 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Is Sole Proprietor N
Indicate whether provider is a sole proprietor.
  • A sole proprietor is the sole (the only) owner of a business that is not incorporated; that unincorporated business is a sole proprietorship.
  • In a sole proprietorship, the sole proprietor owns all of the assets of the business and is solely liable for all of the debts of the business.
  • There is no difference between a sole proprietorship and a sole proprietor; they are legally a single entity: an individual.
  • In terms of NPI assignment, a sole proprietor is an Entity type 1 (Individual) and is eligible for only one NPI (the sole proprietorship business is not eligible for its own NPI).
  • As an individual, a sole proprietorship cannot be a subpart and cannot have subparts. (See NPI Final Rule for information about subparts.)
  • A sole proprietorship may or may not have employees.
  • Often, the IRS assigns an EIN to a sole proprietorship in order to protect the sole proprietor's SSN from disclosure in claims or on W-2s. NPPES does not capture a sole proprietorship's EIN.
  • Many types of health care providers could be sole proprietorships (for example, group practices, pharmacies, home health agencies).
Provider Last Name (Legal Name) Burgess
The last name of the provider (if an individual). If the provider is an individual, this is the legal name. This name must match the name on file with the Social Security Administration (SSA). In addition, the date of birth must match that on file with SSA. (First and last names are required for initial applications.) The First, Middle, Last and Credential(s) fields allow the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters.
Provider First Name Mary
The first name of the provider, if the provider is an individual.
Provider Credential Text MD
The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider First Line Business Mailing Address 4301 W MARKHAM ST # 783
The first line mailing address of the provider being identified. This data element may contain the same information as ''Provider first line location address''.
Provider Business Mailing Address City Name Little Rock
The City name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address City name''.
Provider Business Mailing Address State Name Arkansas
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address State name''.
Provider Business Mailing Address Postal Code 72205-7101
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ''Provider location address postal code''.
Provider Business Mailing Address Country Code US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address country code''.
Provider Business Mailing Address Telephone Number 501-686-8000
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ''Provider location address telephone number''.
Provider Business Mailing Address Fax Number 501-526-5148
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ''Provider location address fax number''.
Provider First Line Business Practice Location Address 4301 W MARKHAM ST # 783
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name Little Rock
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name Arkansas
The State or Province name in the location address of the provider being identified.
Provider Business Practice Location Address Postal Code 72205-7101
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number 501-686-8000
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number 501-526-5148
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date 07/24/2008
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date 08/20/2020
The date that a record was last updated or changed.
Provider Gender Code F
The code designating the provider's gender if the provider is a person.
Provider Gender Female
The provider's gender if the provider is a person.
Healthcare Provider Taxonomy Code #1 207R00000X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 1 A physician who provides long-term, comprehensive care in the office and the hospital, managing both common and complex illness of adolescents, adults and the elderly. Internists are trained in the diagnosis and treatment of cancer, infections and diseases affecting the heart, blood, kidneys, joints and digestive, respiratory and vascular systems. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, mental health and effective treatment of common problems of the eyes, ears, skin, nervous system and reproductive organs.
Healthcare Provider Taxonomy #1
Provider License Number 1 E-8677
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 1 AR
Provider License Number State Code #1
Healthcare Provider Primary Taxonomy Switch 1 N
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.
Healthcare Provider Taxonomy Code #2 207RI0200X
The Health Care Provider Taxonomy code is a unique alphanumeric code, ten characters in length. The code set is structured into three distinct "Levels" including Provider Type, Classification, and Area of Specialization.
Healthcare Provider Taxonomy 2 An internist who deals with infectious diseases of all types and in all organ systems. Conditions requiring selective use of antibiotics call for this special skill. This physician often diagnoses and treats AIDS patients and patients with fevers which have not been explained. Infectious disease specialists may also have expertise in preventive medicine and travel medicine.
Healthcare Provider Taxonomy #2
Provider License Number 2 E-8677
Certain taxonomy selections will require you to enter your license number and the state where the license was issued. Select Foreign Country in the state drop down box if the license was issued outside of United States. The License Number field allows the following special characters: ampersand, apostrophe, colon, comma, forward slash, hyphen, left and right parentheses, period, pound sign, quotation mark, and semi-colon. A field cannot contain all special characters. DO NOT report the Social Security Number (SSN), IRS Individual Taxpayer Identification Number (ITIN) in this section.
Provider License Number State Code 2 AR
Provider License Number State Code #2
Healthcare Provider Primary Taxonomy Switch 2 Y
Primary Taxonomy:
  • X - The primary taxonomy switch is Not Answered;
  • Y - The taxonomy is the primary taxonomy (there can be only one per NPI record);
  • N - The taxonomy is not the primary taxonomy.