Healthcare Provider Details

I. General information

NPI: 1982690491
Provider Name (Legal Business Name): BENJAMIN V TIPTON MPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 07/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CENTRE ST MIDCOAST MEDICAL GROUP
BATH ME
04530-2550
US

IV. Provider business mailing address

108 CENTRE ST MIDCOAST MEDICAL GROUP
BATH ME
04530-2550
US

V. Phone/Fax

Practice location:
  • Phone: 207-386-1800
  • Fax: 207-386-1801
Mailing address:
  • Phone: 207-386-1800
  • Fax: 207-386-1801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA001117
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: