Provider Demographics
NPI:1750380838
Name:AVERY, FRED LINCOLN (MD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:LINCOLN
Last Name:AVERY
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 1:100 BRICKHILL AVENUE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-773-0040
Mailing Address - Fax:207-774-6501
Practice Address - Street 1:85 BRUCE HILL RD
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:ME
Practice Address - Zip Code:04021-3525
Practice Address - Country:US
Practice Address - Phone:207-829-8274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012274207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEB75880Medicare UPIN