Healthcare Provider Details

I. General information

NPI: 1942204466
Provider Name (Legal Business Name): BAIRD MALLORY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BAIRD M SMITH

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST SUITE 300
PORTLAND ME
04102
US

IV. Provider business mailing address

301 US ROUTE 1 BUILDING C
SCARBOROUGH ME
04074-7609
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-5555
  • Fax: 207-662-5526
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number016846
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: