Healthcare Provider Details

I. General information

NPI: 1003881319
Provider Name (Legal Business Name): STEPHAN O. BAMBERGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 04/05/2024
Certification Date: 04/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 GRACELAWN RD
AUBURN ME
04210-6334
US

IV. Provider business mailing address

331 MAINE ST SUITE 5
BRUNSWICK ME
04011-3358
US

V. Phone/Fax

Practice location:
  • Phone: 207-333-4799
  • Fax: 207-333-4767
Mailing address:
  • Phone: 207-798-6974
  • Fax: 207-798-6981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number35.150092
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD14080
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: