1710100839 NPI number — MAINE COAST MOBILE MED, LLC

Table of content: (NPI 1710100839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710100839 NPI number — MAINE COAST MOBILE MED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE COAST MOBILE MED, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1710100839
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1393
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLSWORTH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04605-1393
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-460-8882
Provider Business Mailing Address Fax Number:
207-907-4911

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1576 HAMMOND ST STE C
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:
04401-5751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-404-4894
Provider Business Practice Location Address Fax Number:
207-907-4911
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORST
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-497-2996

Provider Taxonomy Codes

  • Taxonomy code: 335V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 247100000X , with the licence number: RT3575 , 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: 684929 . This is a "TUFTS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 132120000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: MN3768 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 2328397 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: M161680 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 630001645 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 040509 . This is a "BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




Copyright © 2007-2026 www.npivalidator.com