Healthcare Provider Details

I. General information

NPI: 1518537463
Provider Name (Legal Business Name): KRYSTEL ELLIOTT-THEBERGE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 01/10/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 MAIN RD N
HAMPDEN ME
04444-1804
US

IV. Provider business mailing address

603 MAIN RD N
HAMPDEN ME
04444-1804
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-5400
  • Fax: 207-945-8300
Mailing address:
  • Phone: 207-945-5400
  • Fax: 207-945-8300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD24893
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: