Healthcare Provider Details

I. General information

NPI: 1538146402
Provider Name (Legal Business Name): SKOWHEGAN IMAGING ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2005
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 FAIRVIEW AVE
SKOWHEGAN ME
04976-1481
US

IV. Provider business mailing address

PO BOX 1849
LEWISTON ME
04241-1849
US

V. Phone/Fax

Practice location:
  • Phone: 207-474-5121
  • Fax:
Mailing address:
  • Phone: 207-784-2554
  • Fax: 207-777-5363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY VANDYCK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 207-784-2554