MEDICARE: DR. SAMANTHA MARIE BURRILL OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT1038	ME

General Provider Information

NPI Number	:	1265026470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMANTHA MARIE BURRILL OD

Provider Business Mailing Address
First Line	:	743 BROADWAY
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4419
Country	:	US
Telephone Number	:	207-799-3031
Fax Number	:

Provider Business Practice Location Address
First Line	:	743 BROADWAY
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-4419
Country	:	US
Telephone Number	:	207-799-3031
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2021
Last Update Date	:	02/28/2021

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