Provider Demographics
NPI:1548299548
Name:LARSEN, ERIC C (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:C
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:207-661-2033
Practice Address - Street 1:100 CAMPUS DR
Practice Address - Street 2:UNIT 107
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9692
Practice Address - Country:US
Practice Address - Phone:207-885-7565
Practice Address - Fax:207-885-7577
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MEMD16882208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30003473Medicaid
ME431781999Medicaid
NH30003473Medicaid
MEME132302Medicare PIN
MEME132301Medicare PIN
MEME1323Medicare PIN