Healthcare Provider Details

I. General information

NPI: 1023176823
Provider Name (Legal Business Name): ROBERTA BEVERLY GERSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LIVEWELL DR GOODALL OCCUPATIONAL HEALTH CENTER
KENNEBUNK ME
04043-6762
US

IV. Provider business mailing address

459 POOL ST
BIDDEFORD ME
04005-9575
US

V. Phone/Fax

Practice location:
  • Phone: 207-490-7801
  • Fax: 207-604-1018
Mailing address:
  • Phone: 207-282-9008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number1232
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1232
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1232
Identifier TypeOTHER
Identifier StateME
Identifier IssuerSTATE LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: