Healthcare Provider Details

I. General information

NPI: 1750380838
Provider Name (Legal Business Name): FRED LINCOLN AVERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 BRUCE HILL RD
CUMBERLAND ME
04021-3525
US

IV. Provider business mailing address

100 BRICKHILL AVENUE SUITE 303
SOUTH PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-829-8274
  • Fax:
Mailing address:
  • Phone: 207-773-0040
  • Fax: 207-774-6501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number012274
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: