Provider Demographics
NPI:1992982680
Name:RICHARD STOCKWELL, DO, LLC
Entity type:Organization
Organization Name:RICHARD STOCKWELL, DO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:STOCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-854-8200
Mailing Address - Street 1:PMB 2700
Mailing Address - Street 2:4 SCAMMON ST, SUITE 19
Mailing Address - City:SACO
Mailing Address - State:ME
Mailing Address - Zip Code:04072
Mailing Address - Country:US
Mailing Address - Phone:207-282-4704
Mailing Address - Fax:207-286-3218
Practice Address - Street 1:344 CUMBERLAND ST
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-2408
Practice Address - Country:US
Practice Address - Phone:207-854-8200
Practice Address - Fax:207-854-8244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-25
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME246680000Medicaid
ME246680000Medicaid