Healthcare Provider Details

I. General information

NPI: 1538277868
Provider Name (Legal Business Name): KENNETH W LAGEROOS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 08/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 CAMPUS AVE
LEWISTON ME
04240
US

IV. Provider business mailing address

PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8442
  • Fax: 207-777-8425
Mailing address:
  • Phone: 207-777-8950
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberDO1227
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: