Healthcare Provider Details

I. General information

NPI: 1821026055
Provider Name (Legal Business Name): MACARIO F. LICHAUCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 12/20/2023
Certification Date: 12/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST KELLY 6 EASTERN MAINE MEDICAL CENTER
BANGOR ME
04401-6616
US

IV. Provider business mailing address

489 STATE ST KELLY 6 EASTERN MAINE MEDICAL CENTER
BANGOR ME
04401-6616
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-8670
  • Fax: 207-973-5163
Mailing address:
  • Phone: 207-973-8670
  • Fax: 207-973-5163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35149711
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number015508
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35149711
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: