1598069312 NPI number — E. MERLE BRAGDON, PHD, PA

Table of content: (NPI 1598069312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598069312 NPI number — E. MERLE BRAGDON, PHD, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E. MERLE BRAGDON, PHD, 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:
1598069312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
178 MIDDLE ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-4075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-772-1570
Provider Business Mailing Address Fax Number:
207-772-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
178 MIDDLE ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-772-1570
Provider Business Practice Location Address Fax Number:
207-772-2670
Provider Enumeration Date:
01/09/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRAGDON
Authorized Official First Name:
E MERLE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-772-1570

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PS742 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: PS1124 , 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)