MEDICARE: BENJAMIN D LIESS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Y00000X	Otolaryngology Physician	2009014370	MO
2	207Y00000X	Otolaryngology Physician	MD18388	ME
3	207Y00000X	Otolaryngology Physician	T2004016418	MO

General Provider Information

NPI Number	:	1265536445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN D LIESS MD

Provider Business Mailing Address
First Line	:	144 US ROUTE 1 STE 1
Second Line	:
City	:	SCARBOROUGH
State	:	ME
Zip	:	04074-7219
Country	:	US
Telephone Number	:	207-415-4841
Fax Number	:	888-612-5691

Provider Business Practice Location Address
First Line	:	100 FODEN RD, WEST
Second Line	:	SUITE 100
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2327
Country	:	US
Telephone Number	:	207-347-2910
Fax Number	:	207-523-8591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2006
Last Update Date	:	12/03/2025

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