Healthcare Provider Details

I. General information

NPI: 1649616442
Provider Name (Legal Business Name): MICAH GIBBS OWNBEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

190 RIVERSIDE ST SUITE 6B
PORTLAND ME
04103-1073
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2381
  • Fax: 207-662-6226
Mailing address:
  • Phone: 207-661-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD20735
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: