1619015757 NPI number — MR. SHANNON PAUL RECK HS, IDMT

Table of content: MR. SHANNON PAUL RECK HS, IDMT (NPI 1619015757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619015757 NPI number — MR. SHANNON PAUL RECK HS, IDMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RECK
Provider First Name:
SHANNON
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
HS, IDMT
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:
1619015757
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:
144 HAWTHORNE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBROOK
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04092-2756
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-318-2145
Provider Business Mailing Address Fax Number:
207-741-5470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
259 HIGH STREET
Provider Second Line Business Practice Location Address:
US COAST GUARD SECTOR NORTHERN NEW ENGLAND
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-767-0339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2007

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: 247200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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