Healthcare Provider Details

I. General information

NPI: 1801162268
Provider Name (Legal Business Name): JENNIFER MARGARET BURG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 10/17/2022
Certification Date: 10/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST
PORTLAND ME
04102-3100
US

IV. Provider business mailing address

100 CAMPUS DR UNIT 121
SCARBOROUGH ME
04074-7172
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-6368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4301114586
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA10877600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD26022
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: