Healthcare Provider Details

I. General information

NPI: 1598225583
Provider Name (Legal Business Name): BENJAMIN FREDERICK WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/06/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAINE MEDICAL CENTER 22 BRAMHALL STREET
PORTLAND ME
04102
US

IV. Provider business mailing address

96 APPLECREST DR
YARMOUTH ME
04096-8311
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-0111
  • Fax:
Mailing address:
  • Phone: 757-470-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number0101270233
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: