Healthcare Provider Details

I. General information

NPI: 1548299548
Provider Name (Legal Business Name): ERIC C LARSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 CAMPUS DR UNIT 107
SCARBOROUGH ME
04074-9692
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 207-885-7565
  • Fax: 207-885-7577
Mailing address:
  • Phone: 207-661-2000
  • Fax: 207-661-2033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD16882
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD16882
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: