Provider Demographics
NPI:1235222043
Name:AMIDON, PHILLIP B (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:B
Last Name:AMIDON
Suffix:
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 1:447 NORTH MAIN STREET
Mailing Address - Street 2:SEBASTICOOK VALLEY HEALTH
Mailing Address - City:PITTSFIELD
Mailing Address - State:ME
Mailing Address - Zip Code:04967
Mailing Address - Country:US
Mailing Address - Phone:207-487-5261
Mailing Address - Fax:
Practice Address - Street 1:417 STATE STREET, SUITE 121
Practice Address - Street 2:GASTROENTEROLOGY CENTER OF MAINE
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401
Practice Address - Country:US
Practice Address - Phone:207-973-4266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME008744207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME269040099Medicaid
01517801Medicare PIN
B86541Medicare UPIN