Provider Demographics
NPI:1285790030
Name:CALLISON, MARY L (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:L
Last Name:CALLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9422
Mailing Address - Country:US
Mailing Address - Phone:207-283-7000
Mailing Address - Fax:207-282-9128
Practice Address - Street 1:10 GOODALL DRIVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2621
Practice Address - Country:US
Practice Address - Phone:207-490-7790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18602207Q00000X
ME018602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME435883199Medicaid
ME0017010Medicare PIN