Provider Demographics
NPI:1215007109
Name:POLSELLI, AMATO JR (MD)
Entity Type:Individual
Prefix:
First Name:AMATO
Middle Name:
Last Name:POLSELLI
Suffix:JR
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:P.O. BOX 1329
Mailing Address - Street 2:32 MORISON AVE.
Mailing Address - City:WELLS
Mailing Address - State:ME
Mailing Address - Zip Code:04090-1329
Mailing Address - Country:US
Mailing Address - Phone:207-251-4425
Mailing Address - Fax:207-251-4425
Practice Address - Street 1:32 MORISON AVE.
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:ME
Practice Address - Zip Code:04090-1329
Practice Address - Country:US
Practice Address - Phone:207-251-4425
Practice Address - Fax:207-251-4425
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME269620099Medicare ID - Type UnspecifiedSERVICE PROVIDER NUMBER