1114212149 NPI number — MICHAELA O. SILCO DO

Table of content: MICHAELA O. SILCO DO (NPI 1114212149)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114212149 NPI number — MICHAELA O. SILCO DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SILCO
Provider First Name:
MICHAELA
Provider Middle Name:
O.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'ROURKE
Provider Other First Name:
MICHAELA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114212149
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 GANNETT DRIVE
Provider Second Line Business Mailing Address:
SUITE C
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, EAST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-874-1489
Provider Business Practice Location Address Fax Number:
207-523-8590
Provider Enumeration Date:
06/17/2011

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: DO2430 , 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: 1114212149 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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