Healthcare Provider Details

I. General information

NPI: 1932374881
Provider Name (Legal Business Name): EMILY L WESOLOWSKI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MARGINAL WAY SUITE 1000
PORTLAND ME
04101
US

IV. Provider business mailing address

100 GANNETT DR SUITE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-4092
  • Fax: 207-523-8596
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number018891
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: