Basic Information
| Provider Information | |||||||||
| NPI: | 1588620330 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 247 | ||||||||
| Address2: | |||||||||
| City: | NORTH VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049620247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | 2078734514 | ||||||||
| Practice Location | |||||||||
| Address1: | 905 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VASSALBORO | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049893107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078736173 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 05/05/2008 | ||||||||
| 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 | 207R00000X | 010930 | ME | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003751 | 01 | ME | ANTHEM | OTHER | 5225252 | 01 | AETNA NON HMO | OTHER | 0141319 | 01 | AETNA HMO | OTHER | 280480099 | 05 | ME | MEDICAID | 110025993 | 01 | RAILROAD | OTHER | C66280 | 01 | HARVARD PILGRIM | OTHER |