Basic Information
Provider Information | |||||||||
NPI: | 1033318753 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WINGARD | ||||||||
FirstName: | BRANDEI | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
Address2: |   | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 04005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072829080 | ||||||||
FaxNumber: | 2072824281 | ||||||||
Practice Location | |||||||||
Address1: | 9 HEALTHCARE DRIVE | ||||||||
Address2: | SUITE 105 | ||||||||
City: | BIDDEFORD | ||||||||
State: | ME | ||||||||
PostalCode: | 04005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2072823666 | ||||||||
FaxNumber: | 2072824281 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 11/27/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | MD19215 | ME | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207R00000X | MD19215 | ME | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RC0000X | MD19215 | ME | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
ID | Type | State | Issuer | Description | AA316117 | 01 | ME | HARVARD PILGRIM | OTHER | 7840316 | 01 | ME | CIGNA | OTHER | 1033318753 | 01 | ME | ANTHEM | OTHER | 1033318753 | 05 | ME |   | MEDICAID | 9221840 | 01 | ME | AETNA | OTHER |