Healthcare Provider Details

I. General information

NPI: 1699772772
Provider Name (Legal Business Name): RONALD E BAILYN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 10/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MIDDLE ST SUITE 404
PORTLAND ME
04101-4156
US

IV. Provider business mailing address

20 ADELBERT ST
SOUTH PORTLAND ME
04106-6512
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-8634
  • Fax: 207-772-1629
Mailing address:
  • Phone: 207-772-8634
  • Fax: 207-772-1629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number011874
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number011874
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: