1336101104 NPI number — DONALD R BURGESS M.D.

Table of content: DONALD R BURGESS M.D. (NPI 1336101104)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336101104 NPI number — DONALD R BURGESS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURGESS
Provider First Name:
DONALD
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336101104
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
P.O. BOX 626
Provider Business Mailing Address City Name:
BIDDEFORD
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04005-9422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-282-9080
Provider Business Mailing Address Fax Number:
207-985-8459

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3 SHAPE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEBUNK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04043-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-467-8983
Provider Business Practice Location Address Fax Number:
207-467-8981
Provider Enumeration Date:
04/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  014097 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0006X , with the licence number: 014097 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 248080099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1041865 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: MNT053 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 018435 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 30208022 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 610036401 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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