Healthcare Provider Details

I. General information

NPI: 1467658112
Provider Name (Legal Business Name): BENJAMIN WALTER HUERTH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 01/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 WABANAKI WAY
INDIAN ISLAND ME
04468-1252
US

IV. Provider business mailing address

23 WABANAKI WAY
INDIAN ISLAND ME
04468-1252
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-7400
  • Fax: 207-817-7453
Mailing address:
  • Phone: 207-817-7400
  • Fax: 207-817-7459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number018547
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: