Healthcare Provider Details

I. General information

NPI: 1225170624
Provider Name (Legal Business Name): BENJAMIN MICHAEL LANNON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

778 MAIN ST SUITE 2
SOUTH PORTLAND ME
04106-5447
US

IV. Provider business mailing address

778 MAIN ST SUITE 2
SOUTH PORTLAND ME
04106-5447
US

V. Phone/Fax

Practice location:
  • Phone: 207-358-7600
  • Fax: 207-761-7019
Mailing address:
  • Phone: 207-358-7600
  • Fax: 207-761-7019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number217837
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number231397
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: