Basic Information
| Provider Information | |||||||||
| NPI: | 1659489284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOULTANAKIS | ||||||||
| FirstName: | EMMANUEL | ||||||||
| MiddleName: | NICHOLAS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301C US ROUTE 1 | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073968600 | ||||||||
| FaxNumber: | 2073968632 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 CAMPUS DR | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040749692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078830069 | ||||||||
| FaxNumber: | 2078830999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 03/08/2013 | ||||||||
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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 | 207V00000X | 042-0010087 | VT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VX0201X | 042-0010087 | VT | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | 207VX0201X | MD19505 | ME | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 0VN2415 | 05 | VT | MEDICAID | 02118770 | 05 | NY | MEDICAID |