Healthcare Provider Details

I. General information

NPI: 1144541400
Provider Name (Legal Business Name): ALEX S KEUROGHLIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/11/2025
Certification Date: 06/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 VAUGHAN ST
PORTLAND ME
04102-3204
US

IV. Provider business mailing address

216 VAUGHAN ST
PORTLAND ME
04102-3204
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2221
  • Fax: 207-810-2367
Mailing address:
  • Phone: 207-662-2221
  • Fax: 207-810-2367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberL-243919
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD29349
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: