1912133943 NPI number — WELL WOMAN CLINIC, PLLC

Table of content: (NPI 1912133943)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912133943 NPI number — WELL WOMAN CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELL WOMAN CLINIC, PLLC
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:
1912133943
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
174 S FREEPORT RD
Provider Second Line Business Mailing Address:
STE. 1A
Provider Business Mailing Address City Name:
FREEPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04032-6145
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-497-2996
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
174 S FREEPORT RD
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
FREEPORT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04032-6145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-865-7088
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2009

Additional Information

Authorized Official

Authorized Official Last Name:
CORBETT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
BILLING REPRESENTATIVE
Authorized Official Telephone Number:
207-497-2996

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  012979 , 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: 1912133943 . This is a "BCBS" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 434287100 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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