Provider Demographics
NPI:1174762116
Name:SCOLL, BENJAMIN JACOB (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JACOB
Last Name:SCOLL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:195 FORE RIVER PKWY
Mailing Address - Street 2:SUITE 310
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2780
Mailing Address - Country:US
Mailing Address - Phone:207-523-5901
Mailing Address - Fax:207-523-5902
Practice Address - Street 1:195 FORE RIVER PKWY
Practice Address - Street 2:SUITE 310
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2780
Practice Address - Country:US
Practice Address - Phone:207-523-5901
Practice Address - Fax:207-523-5902
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2011-12-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ME018411208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1174762116Medicaid
ME1174762116Medicaid