1790807139 NPI number — SHIPMAN PEDIATRICS, LLC

Table of content: (NPI 1790807139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790807139 NPI number — SHIPMAN PEDIATRICS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHIPMAN PEDIATRICS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1790807139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 MASON BAY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04649-3501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-497-2996
Provider Business Mailing Address Fax Number:
207-497-3467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BRICKYARD LN
Provider Second Line Business Practice Location Address:
UNIT D
Provider Business Practice Location Address City Name:
YORK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
03909-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-497-2996
Provider Business Practice Location Address Fax Number:
207-497-3467
Provider Enumeration Date:
04/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SHIPMAN
Authorized Official First Name:
RUSSELL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
207-497-2996

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  1575 , 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: 5924615 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 047343 . This is a "BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 408230000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: G34607 . This is a "HARVARD PILGRIM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: M121911C . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 2824368 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: M221430 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 30233307 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7496508 . This is a "CIGNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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