1225349830 NPI number — MISTY RAE STARBUCK MOTR-L

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225349830 NPI number — MISTY RAE STARBUCK MOTR-L

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STARBUCK
Provider First Name:
MISTY
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MOTR-L
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MORTON-STARBUCK
Provider Other First Name:
MISTY
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225349830
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92 CUMBERLAND AVE APT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-2648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-318-4681
Provider Business Mailing Address Fax Number:
866-220-5031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
92 CUMBERLAND AVE APT 1
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:
04101-2648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-318-4681
Provider Business Practice Location Address Fax Number:
866-220-5031
Provider Enumeration Date:
06/29/2010

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: 225X00000X , with the licence number:  OT2400 , 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: 1225349830 . This is a "ANTHEM OF MAINE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".