1134192040 NPI number — DRAGONFLY THERAPY

Table of content: (NPI 1134192040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134192040 NPI number — DRAGONFLY THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DRAGONFLY THERAPY
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:
1134192040
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
840 HAMMOND ST STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04401-4339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-433-7778
Provider Business Mailing Address Fax Number:
207-433-7780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
840 HAMMOND ST STE 2
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:
04401-4339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-433-7778
Provider Business Practice Location Address Fax Number:
207-433-7780
Provider Enumeration Date:
02/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HAGGERTY
Authorized Official First Name:
DANIELLE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-433-7778

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1668152 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: AA65965 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 434571000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040462 . This is a "BLUE CROSS & BLUE SHIELD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: DE4681 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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