MEDICARE: AMY K ETZWEILER 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	207R00000X	Internal Medicine Physician	016150	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10655701	OTHER		CAQH

General Provider Information

NPI Number	:	1568469401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY K ETZWEILER MD

Provider Business Mailing Address
First Line	:	108 CENTRE ST
Second Line	:
City	:	BATH
State	:	ME
Zip	:	04530-2550
Country	:	US
Telephone Number	:	207-386-1800
Fax Number	:	207-442-9822

Provider Business Practice Location Address
First Line	:	108 CENTRE ST
Second Line	:
City	:	BATH
State	:	ME
Zip	:	04530-2550
Country	:	US
Telephone Number	:	207-386-1800
Fax Number	:	207-386-1801

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	04/03/2018

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