Provider Demographics
NPI:1033134796
Name:RUSSELL, BENJAMIN LINCOLN (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:LINCOLN
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY
Mailing Address - Street 2:SUITE 420
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2780
Mailing Address - Country:US
Mailing Address - Phone:207-553-6500
Mailing Address - Fax:207-553-6520
Practice Address - Street 1:195 FORE RIVER PKWY
Practice Address - Street 2:SUITE 420
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2780
Practice Address - Country:US
Practice Address - Phone:207-553-6500
Practice Address - Fax:207-553-6520
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2012-02-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME1178208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME245010099Medicaid
ME245010099Medicaid
E38920Medicare UPIN