Healthcare Provider Details

I. General information

NPI: 1831430461
Provider Name (Legal Business Name): EYECARE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 SEWALL ST
PORTLAND ME
04102-2625
US

IV. Provider business mailing address

53 SEWALL ST
PORTLAND ME
04102-2625
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2020
  • Fax: 207-773-7034
Mailing address:
  • Phone: 207-828-2020
  • Fax: 207-773-7034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: LYNN SHORTY
Title or Position: CHIEF OPERATING OFFICER
Credential: RN, CMPE
Phone: 207-791-8234