Provider Demographics
NPI:1063584753
Name:RALSTON, MATTHEW D (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:D
Last Name:RALSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD124722085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME026380OtherANTHEM
ME5403235OtherAETNA
MEC66672OtherHPHC
NH30007027Medicaid
ME339070099Medicaid
MEM52975OtherCIGNA
MEMM2451Medicare ID - Type Unspecified
NHRE7128Medicare ID - Type Unspecified
NH01Y000066NH01OtherANTHEM
MED99838Medicare UPIN
ME1041586OtherAETNA USHC
ME300061948Medicare ID - Type UnspecifiedRAILROAD