Healthcare Provider Details

I. General information

NPI: 1245450832
Provider Name (Legal Business Name): KRYSTIAN W BIGOSINSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVENUE SUITE 303
SOUTH PORTLAND ME
04106
US

IV. Provider business mailing address

301C US ROUTE ONE
SCARBOROUGH ME
04074
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-0040
  • Fax: 207-824-4900
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036121017
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD20416
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: