Healthcare Provider Details

I. General information

NPI: 1093747628
Provider Name (Legal Business Name): STEPHEN J KIRSCH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 11/20/2022
Certification Date: 11/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 CAMPUS DR SUITE 2C
SCARBOROUGH ME
04074-7133
US

IV. Provider business mailing address

301C US ROUTE 1
SCARBOROUGH ME
04074-9701
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-7926
  • Fax: 207-883-1925
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD014178
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD14178
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: