Healthcare Provider Details

I. General information

NPI: 1669403507
Provider Name (Legal Business Name): STEPHEN F OSBORNE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75B JOHN ROBERTS ROAD
SO PORTLAND ME
04106
US

IV. Provider business mailing address

301 US ROUTE 1
SCARBOROUGH ME
04074-7609
US

V. Phone/Fax

Practice location:
  • Phone: 207-775-4151
  • Fax: 207-775-6950
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number008936
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier242790099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: