Healthcare Provider Details

I. General information

NPI: 1285798447
Provider Name (Legal Business Name): THADDEUS T SHATTUCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 03/27/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 SABATTUS ST STE A
LEWISTON ME
04240-5553
US

IV. Provider business mailing address

165 LANCASTER ST
PORTLAND ME
04101-2406
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8959
  • Fax: 207-753-3093
Mailing address:
  • Phone: 207-874-1030
  • Fax: 207-874-1044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License NumberMD18527
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number018527
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: