Healthcare Provider Details

I. General information

NPI: 1679542708
Provider Name (Legal Business Name): TED L SUSSMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 HARTFORD ST SIGRID E TOMPKINS HEALTH CENTER
HOULTON ME
04730-1844
US

IV. Provider business mailing address

20 HARTFORD ST
HOULTON ME
04730-1891
US

V. Phone/Fax

Practice location:
  • Phone: 207-532-4068
  • Fax: 207-532-5974
Mailing address:
  • Phone: 207-532-2900
  • Fax: 207-532-5974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD10269
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: