Healthcare Provider Details

I. General information

NPI: 1720067200
Provider Name (Legal Business Name): STEPHEN FAIRCHILD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BISBEE ST
LISBON ME
04250-6835
US

IV. Provider business mailing address

2 BISBEE ST
LISBON ME
04250-6835
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-5709
  • Fax:
Mailing address:
  • Phone: 207-795-5709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number012455
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: