1659409977 NPI number — FREDERICK CLAPP ROEDIGER M.D.

Table of content: FREDERICK CLAPP ROEDIGER M.D. (NPI 1659409977)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659409977 NPI number — FREDERICK CLAPP ROEDIGER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROEDIGER
Provider First Name:
FREDERICK
Provider Middle Name:
CLAPP
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1659409977
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301C US ROUTE 1
Provider Second Line Business Mailing Address:
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:
1250 FOREST AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04103-1897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-797-5753
Provider Business Practice Location Address Fax Number:
207-797-9571
Provider Enumeration Date:
02/28/2007

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: 207Y00000X , with the licence number:  MD18047 , 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: 30209197 . This is a "NEW HAMPSHIRE MEDICAID" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: P00759644 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 1044199 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: AA146929 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 433941099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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