1700870201 NPI number — ELISSA J CHARBONNEAU DO

Table of content: ELISSA J CHARBONNEAU DO (NPI 1700870201)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700870201 NPI number — ELISSA J CHARBONNEAU DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARBONNEAU
Provider First Name:
ELISSA
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1700870201
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 US ROUTE ONE
Provider Second Line Business Mailing Address:
BUILDING C
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:
24 HAWTHORNE CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YARMOUTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04096-8337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-851-1724
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2005

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: 208100000X , with the licence number:  1399 , 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: 218640049 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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