Basic Information
Provider Information | |||||||||
NPI: | 1023004496 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALWORTH | ||||||||
FirstName: | EDWARD | ||||||||
MiddleName: | Z. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4157 | ||||||||
Address2: | ST. MARY'S HEALTH SYSTEM | ||||||||
City: | BOSTON | ||||||||
State: | MH | ||||||||
PostalCode: | 022114157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077774111 | ||||||||
FaxNumber: | 2077836660 | ||||||||
Practice Location | |||||||||
Address1: | 710 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | LEWISTON | ||||||||
State: | ME | ||||||||
PostalCode: | 042405801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077831449 | ||||||||
FaxNumber: | 2077773865 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2005 | ||||||||
LastUpdateDate: | 01/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 240490099 | 05 | ME |   | MEDICAID |