Basic Information
Provider Information | |||||||||
NPI: | 1023545613 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DITMER | ||||||||
FirstName: | BAILEY | ||||||||
MiddleName: | IVA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | ME | ||||||||
PostalCode: | 049386144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077786031 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 111 FRANKLIN HEALTH CMNS | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | ME | ||||||||
PostalCode: | 049386144 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2077786031 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/15/2017 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 5101022976 | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207P00000X | DO3206 | ME | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 5101024534 | 01 | MI | STATE LICENSE | OTHER | DO3206 | 01 | ME | STATE LICENSE | OTHER |