Healthcare Provider Details

I. General information

NPI: 1821167685
Provider Name (Legal Business Name): EDWARD B PONTIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 BATH RD
BRUNSWICK ME
04011-2673
US

IV. Provider business mailing address

329 BATH RD
BRUNSWICK ME
04011-2673
US

V. Phone/Fax

Practice location:
  • Phone: 800-434-3000
  • Fax:
Mailing address:
  • Phone: 800-434-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number015058
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: