1619900263 NPI number — INGRID J VAN DUIVENBODE PT

Table of content: INGRID J VAN DUIVENBODE PT (NPI 1619900263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619900263 NPI number — INGRID J VAN DUIVENBODE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN DUIVENBODE
Provider First Name:
INGRID
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HATTON
Provider Other First Name:
INGRID
Provider Other Middle Name:
J.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1619900263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GANNETT DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-5900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-828-0361
Provider Business Mailing Address Fax Number:
207-874-1483

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 FODEN RD, WEST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SOUTH PORLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-780-8860
Provider Business Practice Location Address Fax Number:
207-780-8857
Provider Enumeration Date:
07/08/2006

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: 225100000X , with the licence number:  PT2381 , 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: 338210099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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