1952402224 NPI number — JULIE ANN PETERSON, P.A.

Table of content: (NPI 1952402224)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952402224 NPI number — JULIE ANN PETERSON, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JULIE ANN PETERSON, 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:
1952402224
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 633
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWAY
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04268-0633
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-890-8779
Provider Business Mailing Address Fax Number:
207-739-2453

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
28 WINTER ST
Provider Second Line Business Practice Location Address:
UNIT 2
Provider Business Practice Location Address City Name:
NORWAY
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04268-5620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-890-8779
Provider Business Practice Location Address Fax Number:
207-739-2453
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
207-739-2454

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LC8164 , 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: 11328070 . This is a "CAQH PROVIDER NUMBER" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 27611000099 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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