Healthcare Provider Details

I. General information

NPI: 1386690501
Provider Name (Legal Business Name): STEPHEN M WALSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 RIDGEWOOD DR
BANGOR ME
04401-2652
US

IV. Provider business mailing address

78 RIDGEWOOD DR
BANGOR ME
04401-2652
US

V. Phone/Fax

Practice location:
  • Phone: 207-307-8901
  • Fax: 207-307-8911
Mailing address:
  • Phone: 207-947-8381
  • Fax: 207-947-1897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number036115376
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number17389
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: