Healthcare Provider Details

I. General information

NPI: 1659356517
Provider Name (Legal Business Name): ATLANTIC FOOT & ANKLE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 12/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1711 CONGRESS ST
PORTLAND ME
04102-1962
US

IV. Provider business mailing address

1711 CONGRESS ST
PORTLAND ME
04102-1962
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-5800
  • Fax:
Mailing address:
  • Phone: 207-773-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: JOHN PERRY
Title or Position: PRESIDENT
Credential: MD
Phone: 207-773-5800