Basic Information
| Provider Information | |||||||||
| NPI: | 1457382251 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENISER | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | |||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16 COMMUNITY LN | ||||||||
| Address2: | |||||||||
| City: | SOUTHWEST HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046794273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072445630 | ||||||||
| FaxNumber: | 2072442801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 03/07/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2002 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2002 | 01 | ME | ME LICENSE | OTHER | 432646399 | 05 | ME | MEDICAID | 99691 | 01 | ME | ANTHEM | OTHER |