Healthcare Provider Details

I. General information

NPI: 1992751754
Provider Name (Legal Business Name): FRED SIMS STUCKY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 MEDICAL CENTER PKWY
AUGUSTA ME
04330-8160
US

IV. Provider business mailing address

35 MEDICAL CENTER PKWY
AUGUSTA ME
04330-8160
US

V. Phone/Fax

Practice location:
  • Phone: 207-621-4680
  • Fax:
Mailing address:
  • Phone: 207-621-4680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number00017567
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD27794
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: