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General NPI Number Information
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NPI Number | 1811475403
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Entity Type | Individual
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Provider Name | BENJAMIN PHILIP PUSHARD ATC
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Gender | Male
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Dates
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Enumeration Date | 08/06/2018
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Last Update Date | 08/06/2018
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Provider Practice Location Address
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Address Line | 270 WILSON ST SAME
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City | BREWER
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State | ME
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Zip | 04412-1548
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Country | US
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Telephone | 207-989-4401
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Fax |
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Provider Business Mailing Address
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Address Line | 270 WILSON ST
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City | BREWER
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State | ME
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Zip | 04412-1548
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Country | US
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Telephone | 207-989-4401
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | CR2036
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License Number State | ME
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