Basic Information
| Provider Information | |||||||||
| NPI: | 1881048502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NILSSON | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | MMC OP C&A PSYCHIATRY | ||||||||
| Address2: | 66 BRAMHALL STREET | ||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076622160 | ||||||||
| FaxNumber: | 2076626348 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 BRAMHALL ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076622160 | ||||||||
| FaxNumber: | 2076626348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2016 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0804X | MD24084 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.