Healthcare Provider Details

I. General information

NPI: 1548730567
Provider Name (Legal Business Name): PEDS COVERAGE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1577 CONGRESS ST
PORTLAND ME
04102-2169
US

IV. Provider business mailing address

PO BOX 1778
LEWISTON ME
04241-1778
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-1442
  • Fax:
Mailing address:
  • Phone: 207-375-3024
  • Fax: 207-375-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN BLUMENTHAL
Title or Position: OWNER
Credential: MD
Phone: 207-553-6300