MEDICARE: COLLIN MCCLOSKEY LEIBOLD 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	207QS0010X	Sports Medicine (Family Medicine) Physician	MD30314	ME
2	207Q00000X	Family Medicine Physician	MD30314	ME

General Provider Information

NPI Number	:	1629728555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN MCCLOSKEY LEIBOLD MD

Provider Business Mailing Address
First Line	:	49 SPRING ST STE 101
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8926
Country	:	US
Telephone Number	:	207-883-7926
Fax Number	:	207-618-5021

Provider Business Practice Location Address
First Line	:	49 SPRING ST STE 101
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-8926
Country	:	US
Telephone Number	:	207-883-7926
Fax Number	:	207-618-5021

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

Provider Enumeration Date	:	03/24/2022
Last Update Date	:	05/06/2026

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