Healthcare Provider Details

I. General information

NPI: 1891010997
Provider Name (Legal Business Name): ADAM BURCHARD SISE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2010
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 SEWALL ST
PORTLAND ME
04102-2625
US

IV. Provider business mailing address

53 SEWALL ST
PORTLAND ME
04102-2625
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2020
  • Fax:
Mailing address:
  • Phone: 207-828-2020
  • 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 Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD20477
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: