Provider Demographics
NPI:1699958249
Name:MYRON K KRUEGER MD PA
Entity type:Organization
Organization Name:MYRON K KRUEGER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-729-0161
Mailing Address - Street 1:331 MAINE STREET
Mailing Address - Street 2:SUITE 24
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-729-0161
Mailing Address - Fax:207-721-9199
Practice Address - Street 1:765 HIGH STREET
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530
Practice Address - Country:US
Practice Address - Phone:207-443-4010
Practice Address - Fax:207-721-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME6319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1041452OtherAETNA
0018296OtherANTHEM
B86827Medicare UPIN
0018296OtherANTHEM