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General NPI Number Information
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NPI Number | 1508087289
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Entity Type | Organization
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Legal Business Name | PORTLAND GASTROENTEROLOGY ASSOCIATES P.A.
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Dates
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Enumeration Date | 05/01/2007
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Last Update Date | 02/03/2023
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Provider Practice Location Address
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Address Line | 161 MARGINAL WAY
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City | PORTLAND
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State | ME
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Zip | 04101
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Country | US
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Telephone | 207-773-7964
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Fax | 207-773-9073
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Provider Business Mailing Address
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Address Line | 161 MARGINAL WAY
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City | PORTLAND
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State | ME
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Zip | 04101-2438
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Country | US
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Telephone | 207-773-7964
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Fax | 207-773-9073
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MELISSA GOUSSE
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Credential |
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Telephone | 207-773-7964
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RG0100X
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Taxonomy Name | Gastroenterology Physician
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License Number |
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License Number State |
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