Basic Information
| Provider Information | |||||||||
| NPI: | 1063671121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILDWOOD MEDICINE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7412 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073477132 | ||||||||
| FaxNumber: | 2078392197 | ||||||||
| Practice Location | |||||||||
| Address1: | 83 INDIA ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041014210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073477132 | ||||||||
| FaxNumber: | 2078392197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2008 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2073477132 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | PT NC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171100000X | AC281 | ME | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 171100000X | AC308 | ME | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Acupuncturist | 225100000X | PT3116 | ME | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.