Provider Demographics
NPI:1386690501
Name:WALSH, STEPHEN M (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:M
Last Name:WALSH
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 1:78 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2652
Mailing Address - Country:US
Mailing Address - Phone:207-947-8381
Mailing Address - Fax:207-947-1897
Practice Address - Street 1:78 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2652
Practice Address - Country:US
Practice Address - Phone:207-307-8901
Practice Address - Fax:207-307-8911
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115376207XS0114X
ME17389207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432654299Medicaid
P00460654OtherRR MEDICARE