Provider Demographics
NPI:1891728655
Name:ROY, BRENDA M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:M
Last Name:ROY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HARDISON RD
Mailing Address - Street 2:
Mailing Address - City:CARIBOU
Mailing Address - State:ME
Mailing Address - Zip Code:04736-3743
Mailing Address - Country:US
Mailing Address - Phone:207-498-8090
Mailing Address - Fax:
Practice Address - Street 1:163 VAN BUREN RD
Practice Address - Street 2:
Practice Address - City:CARIBOU
Practice Address - State:ME
Practice Address - Zip Code:04736-3567
Practice Address - Country:US
Practice Address - Phone:207-498-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015567174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME258990099Medicaid
300134385OtherRR MEDICARE
ME042816OtherANTHEM BC/BS