Healthcare Provider Details

I. General information

NPI: 1982647178
Provider Name (Legal Business Name): MARK R PUBLICKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 PARK RD
WESTBROOK ME
04092-3176
US

IV. Provider business mailing address

144 STATE ST
PORTLAND ME
04101-3776
US

V. Phone/Fax

Practice location:
  • Phone: 207-857-8383
  • Fax:
Mailing address:
  • Phone: 207-879-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number016555
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: