Basic Information
Provider Information | |||||||||
NPI: | 1477547909 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CERVENKA | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 112 SANFORD RD | ||||||||
Address2: |   | ||||||||
City: | WELLS | ||||||||
State: | ME | ||||||||
PostalCode: | 040905533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076418044 | ||||||||
FaxNumber: | 2076418169 | ||||||||
Practice Location | |||||||||
Address1: | 112 SANFORD RD | ||||||||
Address2: |   | ||||||||
City: | WELLS | ||||||||
State: | ME | ||||||||
PostalCode: | 040905533 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2076418044 | ||||||||
FaxNumber: | 2076418169 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 06/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 6858 | NH | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 00000029 | 05 | NH |   | MEDICAID | 4270144 | 01 | NH | AETNA NON-HMO | OTHER | 0104458Y0NH01 | 01 | NH | ANTHEM | OTHER |