Healthcare Provider Details

I. General information

NPI: 1578581377
Provider Name (Legal Business Name): JUDITH A HIEMENGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/24/2025
Certification Date: 03/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS DR UNIT 121
SCARBOROUGH ME
04074-7172
US

IV. Provider business mailing address

100 CAMPUS DR UNIT 121
SCARBOROUGH ME
04074-7172
US

V. Phone/Fax

Practice location:
  • Phone: 207-396-7270
  • Fax: 207-396-7944
Mailing address:
  • Phone: 207-396-7270
  • Fax: 207-396-7944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberJH046477
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number4301046477
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number4301046477
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberMD26771
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: