Healthcare Provider Details

I. General information

NPI: 1740251172
Provider Name (Legal Business Name): MARY JO MILES CALEBAUGH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 12/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BACK RD
PLEASANT POINT ME
04667-4119
US

IV. Provider business mailing address

11 BACK RD PO BOX 351
PLEASANT POINT ME
04667-4119
US

V. Phone/Fax

Practice location:
  • Phone: 207-853-0644
  • Fax: 207-853-6230
Mailing address:
  • Phone: 207-853-0644
  • Fax: 207-853-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number237412
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: