Healthcare Provider Details

I. General information

NPI: 1144342585
Provider Name (Legal Business Name): PHYSICAL REHABILITATION OF SOUTHERN MAINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 05/21/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 BRIGHTON AVE
PORTLAND ME
04102-2362
US

IV. Provider business mailing address

PO BOX 810
WESTBROOK ME
04098-0810
US

V. Phone/Fax

Practice location:
  • Phone: 207-497-2996
  • Fax: 207-497-3467
Mailing address:
  • Phone: 207-854-1544
  • Fax: 207-854-1516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number014605
License Number StateME

VIII. Authorized Official

Name: MARY A MACY
Title or Position: OWNER
Credential: M.D.
Phone: 207-854-1544