Healthcare Provider Details

I. General information

NPI: 1609941509
Provider Name (Legal Business Name): SOUTHERN MAINE GASTROENTEROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 STORER ST UNIT 106, LAFAYETTE CENTER
KENNEBUNK ME
04043-6875
US

IV. Provider business mailing address

PMB 2700 4 SCAMMON ST, SUITE 19
SACO ME
04072
US

V. Phone/Fax

Practice location:
  • Phone: 207-467-9156
  • Fax: 207-467-9157
Mailing address:
  • Phone: 207-282-4704
  • Fax: 207-286-3218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1428193
Identifier TypeOTHER
Identifier State
Identifier IssuerAETNA
# 2
Identifier878196
Identifier TypeOTHER
Identifier StateME
Identifier IssuerCIGNA
# 3
Identifier432448100
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name: JOHN THOMPSON
Title or Position: PROVIDER
Credential: DO
Phone: 207-467-9156