Provider Demographics
NPI:1932136207
Name:PEVERADA, PHILIP T (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:T
Last Name:PEVERADA
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 1:325B KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4562
Mailing Address - Country:US
Mailing Address - Phone:207-861-6550
Mailing Address - Fax:207-861-6551
Practice Address - Street 1:325B KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4562
Practice Address - Country:US
Practice Address - Phone:207-861-6550
Practice Address - Fax:207-861-6551
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME010265208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1932136207Medicaid
B86388Medicare UPIN
ME1932136207Medicaid
MEMM238901Medicare PIN