Provider Demographics
NPI:1003881319
Name:BAMBERGER, STEPHAN O (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:O
Last Name:BAMBERGER
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 1:331 MAINE ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-3358
Mailing Address - Country:US
Mailing Address - Phone:207-798-6974
Mailing Address - Fax:207-798-6981
Practice Address - Street 1:15 GRACELAWN RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6334
Practice Address - Country:US
Practice Address - Phone:207-333-4799
Practice Address - Fax:207-333-4767
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD140802081P2900X
OH35.150092207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
010424957OtherHARVARD PILGRIM
017157OtherBCBS
010424957OtherAETNA
010424957OtherCHAMPUS
250006007OtherMEDICARE RAILROAD
ME302440099Medicaid
P0061OtherBCBS
250012128OtherMEDICARE RAILROAD
5284750OtherAETNA
606533OtherCIGNA
G12426OtherHARVARD PILGRIM
M58495OtherCIGNA
010424957OtherEMPLOY STANDARDS
010424957OtherSTANDARD TAX ID
010424957OtherTRICARE
G12426Medicare UPIN
010424957OtherAETNA
250012128OtherMEDICARE RAILROAD