Provider Demographics
NPI:1427142165
Name:VANDEN BERG, PETER MARTIN (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:MARTIN
Last Name:VANDEN BERG
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 1:25 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-1167
Mailing Address - Country:US
Mailing Address - Phone:207-647-6000
Mailing Address - Fax:207-647-6260
Practice Address - Street 1:25 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:BRIDGTON
Practice Address - State:ME
Practice Address - Zip Code:04009-1167
Practice Address - Country:US
Practice Address - Phone:207-647-6000
Practice Address - Fax:207-647-6260
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD20535208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400171179Medicare UPIN
MEE400188021Medicare UPIN
OH9299274OtherMEDICARE GROUP #
OHVA4013373Medicare ID - Type Unspecified
OH1891744843OtherBUILDING NPI #
OH2113126OtherMEDICAID GROUP #