Provider Demographics
NPI:1811632680
Name:SEBAGO MEDICAL GROUP INC
Entity type:Organization
Organization Name:SEBAGO MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:ELENA
Authorized Official - Last Name:CHIN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP-BC, APRN-CN
Authorized Official - Phone:207-595-8756
Mailing Address - Street 1:31 PUNKIN VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-3425
Mailing Address - Country:US
Mailing Address - Phone:207-595-8756
Mailing Address - Fax:
Practice Address - Street 1:110 TANDBERG TRL STE G
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5206
Practice Address - Country:US
Practice Address - Phone:207-595-8756
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center