Healthcare Provider Details

I. General information

NPI: 1649625500
Provider Name (Legal Business Name): MICHAEL HENRY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2016
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date: 09/03/2021
Reactivation Date: 09/14/2021

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

324 GANNETT DR STE 200
SOUTH PORTLAND ME
04106-3266
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-0111
  • Fax:
Mailing address:
  • Phone: 207-482-7800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA168636
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberA168636
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD26140
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: