Healthcare Provider Details

I. General information

NPI: 1740219963
Provider Name (Legal Business Name): BURT J YANKIVER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST PAVILION 1203
PORTLAND ME
04102
US

IV. Provider business mailing address

39 WALLACE AVE
SO PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-4618
  • Fax: 207-662-6254
Mailing address:
  • Phone: 207-761-0650
  • Fax: 207-761-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number017131
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number017131
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: