Provider Demographics
NPI:1740219963
Name:YANKIVER, BURT J (MD)
Entity Type:Individual
Prefix:
First Name:BURT
Middle Name:J
Last Name:YANKIVER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SO PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:PAVILION 1203
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-662-4618
Practice Address - Fax:207-662-6254
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2009-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017131207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30207250Medicaid
ME432286499Medicaid
MEP00422098Medicare PIN
NH30207250Medicaid
MEME197801Medicare PIN
MEME197802Medicare PIN