1487691879 NPI number — SOUTHERN MAINE PHYSICAL MEDICINE AND REHABILITATION, PLLC

Table of content: (NPI 1487691879)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487691879 NPI number — SOUTHERN MAINE PHYSICAL MEDICINE AND REHABILITATION, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MAINE PHYSICAL MEDICINE AND REHABILITATION, PLLC
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:
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Provider Other Name Prefix Text:
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NPI Number Information

NPI Number:
1487691879
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 178
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GORHAM
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04038-0178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-893-2992
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
335 BRIGHTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04102-2362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-775-4000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
ELWOOD
Authorized Official Middle Name:
I
Authorized Official Title or Position:
PRESIDENT/PHYSICIAN
Authorized Official Telephone Number:
207-893-2992

Provider Taxonomy Codes

  • Taxonomy code: 204C00000X , with the licence number:  1709 , 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)





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