Provider Demographics
NPI:1831179803
Name:STADNICKI, MICHAEL
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:STADNICKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 HIGH ST
Mailing Address - Street 2:STE 302
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7634
Mailing Address - Country:US
Mailing Address - Phone:207-795-5750
Mailing Address - Fax:207-795-5649
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:STE 302
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7634
Practice Address - Country:US
Practice Address - Phone:207-795-5709
Practice Address - Fax:207-795-5649
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016038207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010211494Medicaid
ME010211494Medicaid
MEMM9830Medicare ID - Type Unspecified