Healthcare Provider Details

I. General information

NPI: 1003248436
Provider Name (Legal Business Name): FORE RIVER UROLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2013
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 DONALD B DEAN DR SUITE 1
SOUTH PORTLAND ME
04106-3252
US

IV. Provider business mailing address

21 DONALD B DEAN DR SUITE 1
SOUTH PORTLAND ME
04106-3252
US

V. Phone/Fax

Practice location:
  • Phone: 207-776-2411
  • Fax:
Mailing address:
  • Phone: 207-776-2411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MEGAN SHOREY
Title or Position: OFFICE MANAGER
Credential:
Phone: 207-776-2411