Healthcare Provider Details

I. General information

NPI: 1366541906
Provider Name (Legal Business Name): JOHN C SOUTHALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 WATER STREET
BLUE HILL ME
04614
US

IV. Provider business mailing address

57 WATER STREET
BLUE HILL ME
04614
US

V. Phone/Fax

Practice location:
  • Phone: 207-374-3473
  • Fax: 207-374-3989
Mailing address:
  • Phone: 207-374-3473
  • Fax: 207-374-3989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD15937
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: