Provider Demographics
NPI:1114935855
Name:MELISSA PARK, MD INTERNAL MEDICINE
Entity Type:Organization
Organization Name:MELISSA PARK, MD INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-594-2609
Mailing Address - Street 1:4 GLEN COVE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-4235
Mailing Address - Country:US
Mailing Address - Phone:207-594-2609
Mailing Address - Fax:207-594-4358
Practice Address - Street 1:4 GLEN COVE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-4235
Practice Address - Country:US
Practice Address - Phone:207-594-2609
Practice Address - Fax:207-594-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015943174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1397Medicare ID - Type Unspecified
MEH39880Medicare UPIN