1477578268 NPI number — MAINE FELDENKRAIS & PHYSICAL THERAPY

Table of content: (NPI 1477578268)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477578268 NPI number — MAINE FELDENKRAIS & PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE FELDENKRAIS & PHYSICAL THERAPY
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:
Provider Other Organization Name Type Code:
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:
1477578268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
34 HENNESSEY AVE.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRUNSWICK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04011-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-725-7578
Provider Business Mailing Address Fax Number:
207-725-7549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34 HENNESSEY AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRUNSWICK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04011-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-725-7578
Provider Business Practice Location Address Fax Number:
207-725-7549
Provider Enumeration Date:
07/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-725-7578

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT741 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT745 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7202133 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 174463443 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 039001 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 039097 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 131970000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2374315 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 031460426 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".




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