Provider Demographics
NPI:1073045308
Name:SHALLCROSS, ALICE E (DO)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:E
Last Name:SHALLCROSS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8100
Mailing Address - Fax:
Practice Address - Street 1:242 BRUNSWICK ST
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1613
Practice Address - Country:US
Practice Address - Phone:207-827-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS16738207Q00000X
390200000X
MEDO3691207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106254100Medicaid