Basic Information
| Provider Information | |||||||||
| NPI: | 1043374044 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUSAM VALLEY ORTHOPAEDICS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 COTTAGE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040731828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241488 | ||||||||
| FaxNumber: | 2074905733 | ||||||||
| Practice Location | |||||||||
| Address1: | 312 COTTAGE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040731828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073241488 | ||||||||
| FaxNumber: | 2074905733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2006 | ||||||||
| LastUpdateDate: | 01/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | LEBAR | ||||||||
| AuthorizedOfficialFirstName: | RANDI | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2073241488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.