Provider Demographics
NPI:1801993092
Name:PTACIN, PHILIP COURTNEY (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:COURTNEY
Last Name:PTACIN
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 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:61 BARRA RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9459
Practice Address - Country:US
Practice Address - Phone:207-283-1441
Practice Address - Fax:207-523-1136
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD21965207Q00000X
MI4301039477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080062297OtherMEDICARE RAIL ROAD
MI0132967OtherPHP
MI0801329671OtherBLUE CROSS BLUE SHIELD
MI032967OtherBLUE CARE NETWORK
MI2589658Medicaid
MIP01470005Medicare ID - Type Unspecified
MI2589658Medicaid