Healthcare Provider Details

I. General information

NPI: 1255356440
Provider Name (Legal Business Name): KEVYN L COMSTOCK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MOUNT HOPE AVE STE 210
BANGOR ME
04401-5655
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-3030
  • Fax: 207-907-3031
Mailing address:
  • Phone: 207-777-8560
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO1817
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberDO1817
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: