MEDICARE: DR. RICHARD E. NILSON MD

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	2084P0800X	Psychiatry Physician	MD18594	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	010021117CT01	OTHER	CT	ANTHEM BLUE CROSS BLUE SH

General Provider Information

NPI Number	:	1154347524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD E. NILSON MD

Provider Business Mailing Address
First Line	:	78 ATLANTIC PL
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2316
Country	:	US
Telephone Number	:	207-661-6654
Fax Number	:	207-842-7773

Provider Business Practice Location Address
First Line	:	12 UNION ST
Second Line	:
City	:	ROCKLAND
State	:	ME
Zip	:	04841-2739
Country	:	US
Telephone Number	:	207-701-4400
Fax Number	:	207-701-4487

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

Provider Enumeration Date	:	07/15/2006
Last Update Date	:	07/15/2016

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