1689635674 NPI number — MRS. MARY L WOODBURY OTRL

Table of content: MRS. MARY L WOODBURY OTRL (NPI 1689635674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689635674 NPI number — MRS. MARY L WOODBURY OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WOODBURY
Provider First Name:
MARY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEBEL
Provider Other First Name:
MARY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1689635674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
324 GANNETT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-3270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-482-7800
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 MINOT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04210-3922
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-783-1328
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/29/2006

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: 225XH1200X , with the licence number:  OT421 , 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)





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