Healthcare Provider Details

I. General information

NPI: 1487256186
Provider Name (Legal Business Name): BISHOP MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2020
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 FOREST AVE STE 201
PORTLAND ME
04103-6403
US

IV. Provider business mailing address

1250 FOREST AVE STE 201
PORTLAND ME
04103-6403
US

V. Phone/Fax

Practice location:
  • Phone: 207-671-3047
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN BURO
Title or Position: MANAGER
Credential:
Phone: 207-910-6580