1043297179 NPI number — MAINE OTOLARYNGOLOGY SURGERY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043297179 NPI number — MAINE OTOLARYNGOLOGY SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE OTOLARYNGOLOGY SURGERY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MOSA
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043297179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/25/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
116 NORTHPORT AVE
Provider Second Line Business Mailing Address:
SUITE 118
Provider Business Mailing Address City Name:
BELFAST
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04915-6095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-338-4409
Provider Business Mailing Address Fax Number:
207-338-4486

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 NORTHPORT AVE
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
BELFAST
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04915-6095
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-338-4409
Provider Business Practice Location Address Fax Number:
207-338-4486
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RICHTER
Authorized Official First Name:
ELIZABETH
Authorized Official Middle Name:
ANNE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-338-4409

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  015045 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 189920000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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