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General NPI Number Information
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NPI Number | 1144342585
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Entity Type | Organization
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Legal Business Name | PHYSICAL REHABILITATION OF SOUTHERN MAINE PC
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Dates
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Enumeration Date | 04/05/2007
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Last Update Date | 05/21/2020
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Provider Practice Location Address
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Address Line | 335 BRIGHTON AVE
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City | PORTLAND
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State | ME
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Zip | 04102-2362
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Country | US
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Telephone | 207-497-2996
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Fax | 207-497-3467
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Provider Business Mailing Address
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Address Line | PO BOX 810
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City | WESTBROOK
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State | ME
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Zip | 04098-0810
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Country | US
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Telephone | 207-854-1544
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Fax | 207-854-1516
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Authorized Official
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Title or Position | OWNER
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Name | MARY A MACY
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Credential | M.D.
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Telephone | 207-854-1544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 014605
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License Number State | ME
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