Provider Demographics
NPI:1538113063
Name:PORTLAND OSTEOPATHIC, PA
Entity Type:Organization
Organization Name:PORTLAND OSTEOPATHIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:ZOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-221-2355
Mailing Address - Street 1:PO BOX 4022
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-0222
Mailing Address - Country:US
Mailing Address - Phone:207-221-2355
Mailing Address - Fax:207-221-2356
Practice Address - Street 1:208 VAUGHAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3204
Practice Address - Country:US
Practice Address - Phone:207-221-2355
Practice Address - Fax:207-221-2356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1715204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty