1578771465 NPI number — NORTHERN MAINE ORAL & FACIAL SURGERY PA

Table of content: (NPI 1578771465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578771465 NPI number — NORTHERN MAINE ORAL & FACIAL SURGERY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHERN MAINE ORAL & FACIAL SURGERY PA
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:
1578771465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
181 ACADEMY STREET
Provider Second Line Business Mailing Address:
SUITE #1
Provider Business Mailing Address City Name:
PRESQUE ISLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04769-3178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-764-6337
Provider Business Mailing Address Fax Number:
207-764-1446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
181 ACADEMY STREET
Provider Second Line Business Practice Location Address:
SUITE #1
Provider Business Practice Location Address City Name:
PRESQUE ISLE
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04769-3178
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-764-6337
Provider Business Practice Location Address Fax Number:
207-764-1446
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROONEY
Authorized Official First Name:
DEBBIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
207-764-6337

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  3426 , 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: 9760835 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 132730000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2209645 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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