Healthcare Provider Details

I. General information

NPI: 1386761567
Provider Name (Legal Business Name): COSMINA I FACHIOL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 01/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST
BANGOR ME
04401-6616
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1005
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7000
  • Fax: 207-973-5042
Mailing address:
  • Phone: 207-973-5035
  • Fax: 207-973-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD18653
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License NumberMD18653
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD18653
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: