Healthcare Provider Details

I. General information

NPI: 1285790030
Provider Name (Legal Business Name): MARY L CALLISON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GOODALL DRIVE
SANFORD ME
04073-2621
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
BIDDEFORD ME
04005-9422
US

V. Phone/Fax

Practice location:
  • Phone: 207-490-7790
  • Fax:
Mailing address:
  • Phone: 207-283-7000
  • Fax: 207-282-9128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD18602
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: