Healthcare Provider Details

I. General information

NPI: 1457342966
Provider Name (Legal Business Name): BILLY WADE MAHANEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/21/2023
Certification Date: 05/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MEDICAL CENTER DR
BRUNSWICK ME
04011-2652
US

IV. Provider business mailing address

157 PRINCES POINT RD
BRUNSWICK ME
04011-3729
US

V. Phone/Fax

Practice location:
  • Phone: 207-373-6838
  • Fax:
Mailing address:
  • Phone: 201-867-6427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberD0075283
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberM8806
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD22871
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: