Healthcare Provider Details

I. General information

NPI: 1477547909
Provider Name (Legal Business Name): ROBERT P CERVENKA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 SANFORD RD
WELLS ME
04090-5533
US

IV. Provider business mailing address

112 SANFORD RD
WELLS ME
04090-5533
US

V. Phone/Fax

Practice location:
  • Phone: 207-641-8044
  • Fax: 207-641-8169
Mailing address:
  • Phone: 207-641-8044
  • Fax: 207-641-8169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number6858
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: