1164698569 NPI number — PIP HIDESTRAND M.D.

Table of content: PIP HIDESTRAND M.D. (NPI 1164698569)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164698569 NPI number — PIP HIDESTRAND M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HIDESTRAND
Provider First Name:
PIP
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUANG
Provider Other First Name:
PIP
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164698569
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
43 WHITING HILL RD STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BREWER
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04412-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-973-8885
Provider Business Mailing Address Fax Number:
207-973-8817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
417 STATE ST STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-6654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-973-8585
Provider Business Practice Location Address Fax Number:
207-973-8817
Provider Enumeration Date:
05/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X , with the licence number:  MD20555 , 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: 1164698569 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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