Provider Demographics
NPI:1801984844
Name:MYRON K KRUEGER MD PA
Entity type:Organization
Organization Name:MYRON K KRUEGER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRON
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:207-729-0161
Mailing Address - Street 1:331 MAINE STREET
Mailing Address - Street 2:SUITE 24
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-729-0161
Mailing Address - Fax:207-721-9199
Practice Address - Street 1:331 MAINE STREET
Practice Address - Street 2:SUITE 24
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-729-0161
Practice Address - Fax:207-721-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2007-11-09
Deactivation Date:2007-02-13
Deactivation Code:
Reactivation Date:2007-11-09
Provider Licenses
StateLicense IDTaxonomies
ME6319207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1041452OtherAETNA
ME0018296OtherANTHEM BCBS OF ME
MM6656Medicare ID - Type Unspecified
B86827Medicare UPIN