Provider Demographics
NPI:1639155393
Name:SIVULICH, MICHAEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:SIVULICH
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:PO BOX 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8553
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:93 CAMPUS AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-6030
Practice Address - Country:US
Practice Address - Phone:207-755-3636
Practice Address - Fax:207-755-3652
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME11922207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
100005851OtherRAILROAD MEDICARE
1040131OtherAETNA
ME309480099Medicaid
002390OtherANTHEM
1040131OtherAETNA
MEMM030902Medicare PIN
ME309480099Medicaid
MEMM030901Medicare PIN