Healthcare Provider Details

I. General information

NPI: 1417043639
Provider Name (Legal Business Name): PETER H WITHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 COMMUNITY LN
SOUTHWEST HARBOR ME
04679-4273
US

IV. Provider business mailing address

50 UNION STREET
ELLSWORTH ME
04605
US

V. Phone/Fax

Practice location:
  • Phone: 207-244-5630
  • Fax:
Mailing address:
  • Phone: 207-664-7780
  • Fax: 207-664-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD19832
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0420010126
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: