1902021447 NPI number — WESTERN MAINE MULTI MEDICAL SPECIALIST

Table of content: (NPI 1902021447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902021447 NPI number — WESTERN MAINE MULTI MEDICAL SPECIALIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN MAINE MULTI MEDICAL SPECIALIST
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:
WESTERN MAINE PEDIATRICS
Provider Other Organization Name Type Code:
3
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:
1902021447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 US ROUTE ONE
Provider Second Line Business Mailing Address:
BUILDING C
Provider Business Mailing Address City Name:
SCARBOROUGH
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04074-9701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-396-8600
Provider Business Mailing Address Fax Number:
207-396-8632

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
193 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
NORWAY
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04268-5645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-743-8766
Provider Business Practice Location Address Fax Number:
207-743-1579
Provider Enumeration Date:
04/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COX
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
SR. VP- FISCAL
Authorized Official Telephone Number:
207-743-9292

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 127080000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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