MEDICARE: JONATHAN T FANBURG MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	MD14878	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275574311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN T FANBURG MD

Provider Business Mailing Address
First Line	:	301C US ROUTE 1
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-9701
Country	:	US
Telephone Number	:	207-396-8600
Fax Number	:	207-396-8632

Provider Business Practice Location Address
First Line	:	5 BUCKNAM ROAD
Second Line	:	SUITE 1D
City	:	FALMOUTH
State	:	ME
Zip	:	04105-1208
Country	:	US
Telephone Number	:	207-781-1775
Fax Number	:	207-781-1780

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	06/26/2012

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