Healthcare Provider Details

I. General information

NPI: 1154347524
Provider Name (Legal Business Name): RICHARD E. NILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 UNION ST
ROCKLAND ME
04841-2739
US

IV. Provider business mailing address

78 ATLANTIC PL
SOUTH PORTLAND ME
04106-2316
US

V. Phone/Fax

Practice location:
  • Phone: 207-701-4400
  • Fax: 207-701-4487
Mailing address:
  • Phone: 207-661-6654
  • Fax: 207-842-7773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD18594
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: