Healthcare Provider Details

I. General information

NPI: 1043297179
Provider Name (Legal Business Name): MAINE OTOLARYNGOLOGY SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 NORTHPORT AVE SUITE 118
BELFAST ME
04915-6095
US

IV. Provider business mailing address

116 NORTHPORT AVE SUITE 118
BELFAST ME
04915-6095
US

V. Phone/Fax

Practice location:
  • Phone: 207-338-4409
  • Fax: 207-338-4486
Mailing address:
  • Phone: 207-338-4409
  • Fax: 207-338-4486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number015045
License Number StateME

VIII. Authorized Official

Name: DR. ELIZABETH ANNE RICHTER
Title or Position: PRESIDENT
Credential: MD
Phone: 207-338-4409