Provider Demographics
NPI:1114212149
Name:SILCO, MICHAELA O (DO)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:O
Last Name:SILCO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:R
Other - Last Name:O'ROURKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD, EAST
Practice Address - Street 2:SUITE 203
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:207-523-8590
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEDO2430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1114212149Medicaid