Provider Demographics
NPI:1497076814
Name:SKINNER, MICHELLE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:SKINNER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12622
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4017
Mailing Address - Country:US
Mailing Address - Phone:443-481-6576
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2401 BRANDERMILL BLVD
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1690
Practice Address - Country:US
Practice Address - Phone:410-721-1507
Practice Address - Fax:410-721-1510
Is Sole Proprietor?:No
Enumeration Date:2010-06-21
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810026534Medicaid
WVWV3202B987Medicare PIN
422285Y5ZMedicare PIN