1881679116 NPI number — BANGOR SURGICAL ASSOCIATES, P.A.

Table of content: (NPI 1881679116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881679116 NPI number — BANGOR SURGICAL ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BANGOR SURGICAL ASSOCIATES, P.A.
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:
1881679116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
358 BROADWAY
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04401-3929
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-947-5503
Provider Business Mailing Address Fax Number:
207-947-8578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
358 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
BANGOR
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04401-3929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-947-5503
Provider Business Practice Location Address Fax Number:
207-947-8578
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VANADIA
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
207-947-5503

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  1149 , 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: 2677016 . This is a "CIGNA PROVIDER NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 134040000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 040754 . This is a "ANTHEM BS PROVIDER #" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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