Healthcare Provider Details

I. General information

NPI: 1861854119
Provider Name (Legal Business Name): NICHOLAS MILES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 WASHINGTON AVE STE 100
PORTLAND ME
04103-2842
US

IV. Provider business mailing address

901 WASHINGTON AVE STE 100
PORTLAND ME
04103-2842
US

V. Phone/Fax

Practice location:
  • Phone: 207-871-1200
  • Fax: 207-871-1232
Mailing address:
  • Phone: 207-871-1200
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080C0008X
TaxonomyChild Abuse Pediatrics Physician
License NumberMD25720
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: