Healthcare Provider Details

I. General information

NPI: 1104271782
Provider Name (Legal Business Name): JOHN MICHAEL TEDESCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
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: 207-396-7788
  • Fax: 207-396-8500
Mailing address:
  • Phone: 207-396-7788
  • Fax: 207-396-8500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD30744
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD30744
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number69235
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: