Healthcare Provider Details

I. General information

NPI: 1083781264
Provider Name (Legal Business Name): SHANNON M MARCHEGIANI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NICU PROFESSIONAL SERVICES, KELLEY 6 489 STATE STREET
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: 207-973-8670
  • Fax:
Mailing address:
  • Phone: 240-994-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101240575
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberMD22718
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: