Healthcare Provider Details

I. General information

NPI: 1407897614
Provider Name (Legal Business Name): SHANNON MARIE MEREDITH DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 08/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 FORE RIVER PKWY SUITE 210
PORTLAND ME
04102-2780
US

IV. Provider business mailing address

144 STATE ST
PORTLAND ME
04101-3776
US

V. Phone/Fax

Practice location:
  • Phone: 207-553-6682
  • Fax: 207-553-6681
Mailing address:
  • Phone: 207-879-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1000
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: