1235163890 NPI number — EARL R FREEMAN JR. D.O.

Table of content: EARL R FREEMAN JR. D.O. (NPI 1235163890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235163890 NPI number — EARL R FREEMAN JR. D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREEMAN
Provider First Name:
EARL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
D.O.
Provider Gender Code:
M

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:
1235163890
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 648
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEBUNKPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04046-0648
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-967-3726
Provider Business Mailing Address Fax Number:
207-967-3702

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21 WESTERN AVE # A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEBUNK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04043-7354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-967-3726
Provider Business Practice Location Address Fax Number:
207-967-3702
Provider Enumeration Date:
07/10/2006

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: 207Q00000X , with the licence number:  835 , 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: 060928 . This is a "ANTHEM BX/BS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 206880000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 352215816 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".