Healthcare Provider Details

I. General information

NPI: 1720156375
Provider Name (Legal Business Name): JOHN R MCGILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 STATE STREET WEBBER WEST SUITE 443
BANGOR ME
04401
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-9950
  • Fax: 207-973-6966
Mailing address:
  • Phone: 207-973-9950
  • Fax: 207-973-6966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number009457
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: