1659573731 NPI number — DR. E. MERLE BRAGDON PH.D.

Table of content: DR. E. MERLE BRAGDON PH.D. (NPI 1659573731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659573731 NPI number — DR. E. MERLE BRAGDON PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAGDON
Provider First Name:
E.
Provider Middle Name:
MERLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
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:
1659573731
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
178 MIDDLE ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04101-4075
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-772-1570
Provider Business Mailing Address Fax Number:
207-772-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
178 MIDDLE ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04101-4075
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-772-1570
Provider Business Practice Location Address Fax Number:
207-772-2670
Provider Enumeration Date:
06/01/2007

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: 103TC0700X , with the licence number:  PS742 , 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: 373948 . This is a "VALUE OPTIONS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 170033 . This is a "ANTHEM BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: E007054 . This is a "CHAMPUS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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