Healthcare Provider Details

I. General information

NPI: 1285665828
Provider Name (Legal Business Name): RICHARD T MARINO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 12/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 BRAMHALL ST
PORTLAND ME
04102-3344
US

IV. Provider business mailing address

190 RIVERSIDE ST UNIT 6B
PORTLAND ME
04103-1073
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-3157
  • Fax: 207-662-4257
Mailing address:
  • Phone: 207-661-2000
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD16511
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD16511
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: