Healthcare Provider Details

I. General information

NPI: 1790807139
Provider Name (Legal Business Name): SHIPMAN PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRICKYARD LN UNIT D
YORK ME
03909-1604
US

IV. Provider business mailing address

541 MASON BAY RD
JONESPORT ME
04649-3501
US

V. Phone/Fax

Practice location:
  • Phone: 207-497-2996
  • Fax: 207-497-3467
Mailing address:
  • Phone: 207-497-2996
  • Fax: 207-497-3467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1575
License Number StateME

VIII. Authorized Official

Name: RUSSELL SHIPMAN
Title or Position: OWNER
Credential: M.D.
Phone: 207-497-2996