Basic Information
| Provider Information | |||||||||
| NPI: | 1043389745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | TOBY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GARD-WEISS | ||||||||
| OtherFirstName: | TOBY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 887 CONGRESS ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077715549 | ||||||||
| FaxNumber: | 2077717834 | ||||||||
| Practice Location | |||||||||
| Address1: | 887 CONGRESS ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041023166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077715549 | ||||||||
| FaxNumber: | 2077717834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 02153 | ME | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1043389745 | 05 | ME | MEDICAID | AA182841 | 01 | HARVARD | OTHER | 9979562 | 01 | AETNA | OTHER | 2103148 | 01 | CIGNA | OTHER |