1043224330 NPI number — MID-MAINE INTERNAL MEDICINE

Table of content: (NPI 1043224330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043224330 NPI number — MID-MAINE INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MID-MAINE INTERNAL MEDICINE
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:
6
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:
1043224330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 247
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
N VASSALBORO
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04962-0247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-873-6173
Provider Business Mailing Address Fax Number:
207-873-4514

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH VASSALBORO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04962
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-873-6173
Provider Business Practice Location Address Fax Number:
207-873-4514
Provider Enumeration Date:
07/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURKE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-873-6173

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C20487 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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