Basic Information
| Provider Information | |||||||||
| NPI: | 1043224330 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MID-MAINE INTERNAL MEDICINE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BURKE,SMITH & PRESTON, MD,PA | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | N VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049620247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NORTH VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | BURKE | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2078736173 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | C20487 | 01 | RAILROAD MEDICARE | OTHER |