Healthcare Provider Details

I. General information

NPI: 1942562384
Provider Name (Legal Business Name): STEPHANIE EVE OWEN MCCULLOUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE EVE OWEN

II. Dates (important events)

Enumeration Date: 06/12/2012
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WAYMAN LN
BAR HARBOR ME
04609-1625
US

IV. Provider business mailing address

67 KINGSMARK LN
PORTLAND ME
04102-1628
US

V. Phone/Fax

Practice location:
  • Phone: 207-288-5081
  • Fax:
Mailing address:
  • Phone: 813-245-7801
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD22487
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD22487
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: