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General NPI Number Information
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NPI Number | 1467608836
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Entity Type | Organization
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Legal Business Name | MDFPR
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Dates
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Enumeration Date | 08/17/2008
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Last Update Date | 08/17/2008
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Provider Practice Location Address
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Address Line | 15 E CHESTNUT ST
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City | AUGUSTA
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State | ME
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Zip | 04330-5736
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Country | US
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Telephone | 207-626-1889
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Fax |
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Provider Business Mailing Address
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Address Line | 32 QUARRY RD APT 33
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City | WATERVILLE
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State | ME
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Zip | 04901-4970
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Country | US
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Telephone | 415-314-0144
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Fax |
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Authorized Official
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Title or Position | GERIATRICIAN
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Name | KIRILL V BEREJNOI
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Credential | M.D.,
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Telephone | 415-314-0144
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number | A102844
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License Number State | CA
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