Provider Demographics
NPI:1417020041
Name:SOUTHERN MAINE FOOT AND ANKLE PA
Entity type:Organization
Organization Name:SOUTHERN MAINE FOOT AND ANKLE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:OCAMPO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:207-883-0865
Mailing Address - Street 1:25 PLAZA DR
Mailing Address - Street 2:SUITE 9
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-6900
Mailing Address - Country:US
Mailing Address - Phone:207-883-0865
Mailing Address - Fax:207-883-0913
Practice Address - Street 1:25 PLAZA DR
Practice Address - Street 2:SUITE 9
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-6900
Practice Address - Country:US
Practice Address - Phone:207-883-0865
Practice Address - Fax:207-883-0913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD1031213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME5072810001Medicare NSC