Healthcare Provider Details

I. General information

NPI: 1336101104
Provider Name (Legal Business Name): DONALD R BURGESS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 SHAPE DR
KENNEBUNK ME
04043-6601
US

IV. Provider business mailing address

1 MEDICAL CENTER DR P.O. BOX 626
BIDDEFORD ME
04005-9422
US

V. Phone/Fax

Practice location:
  • Phone: 207-467-8983
  • Fax: 207-467-8981
Mailing address:
  • Phone: 207-282-9080
  • Fax: 207-985-8459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number014097
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number014097
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier248080099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer
# 2
Identifier1041865
Identifier TypeOTHER
Identifier StateME
Identifier IssuerAETNA
# 3
IdentifierMNT053
Identifier TypeOTHER
Identifier StateME
Identifier IssuerHARVARD PILGRIM
# 4
Identifier018435
Identifier TypeOTHER
Identifier StateME
Identifier IssuerANTHEM
# 5
Identifier30208022
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer
# 6
Identifier610036401
Identifier TypeOTHER
Identifier StateME
Identifier IssuerCIGNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: