Basic Information
| Provider Information | |||||||||
| NPI: | 1104853001 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BURTIS | ||||||||
| FirstName: | MATIJA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 190 RIVERSIDE STREET | ||||||||
| Address2: | SUITE 6B | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076612095 | ||||||||
| FaxNumber: | 2076612033 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 ANDOVER RD | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076616064 | ||||||||
| FaxNumber: | 2072536073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1685 | ME | N | Allopathic & Osteopathic Physicians | Family Medicine | 2083B0002X | DO1685 | ME | Y |
ID Information
| ID | Type | State | Issuer | Description | 312400099 | 05 | ME | MEDICAID |