1649234378 NPI number — BETHANY T LAKE MD

Table of content: MR. MICHAEL JESSE LEWIS IDC (NPI 1336342591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649234378 NPI number — BETHANY T LAKE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LAKE
Provider First Name:
BETHANY
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1649234378
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MEDICAL CENTER DRIVE
Provider Second Line Business Mailing Address:
PO BOX 626
Provider Business Mailing Address City Name:
BIDDEFORD
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-282-9080
Provider Business Mailing Address Fax Number:
207-282-9180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 GOODALL DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
E. WATERBORO
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-490-7970
Provider Business Practice Location Address Fax Number:
207-282-9128
Provider Enumeration Date:
04/12/2006

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: 207Q00000X , with the licence number:  015660 , 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: 247150099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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